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AOTISEPTIC    SUEGEEY. 

THE   PRINCIPLES,  MODES   OF  APPLICATION, 
AND    RESULTS    OF 

THE    LISTER    DRESSING. 


BY 


DR.   JUST   LUCAS-CHAMPIONNIERE, 

SUBGEON    TO    THE    HoPITAL    TENON,   MEMBER    OP    THE    SOCliiTli    DE    CHIK0EGIE, 
EDITOR  OF  THE  JOURNAL  DE  MEDICINE  ET  DE  CHIRURGIE  PRATIQUES. 


TRANSLATED     FROM     THE     SECOND     AND     COMPLETELY    REVISED    EDITION,    WITH 
THE    SPECIAL   SANCTION    OP    THE    AUTHOR, 

AND    EDITED    BY 

FREDERIC   HENRY   GERRISH,  A.M.,  M.D., 

SURGEON    TO    THE    MAINE    GENERAL    HOSPITAL, 

PROFESSOR    OF   MATERIA    MEDICA   AND    THERAPEUTICS    IN 

BOWDOIN    COLLEGE,    ETC. 


PORTLAND: 
LORING,   SHORT,   AND    HARMON. 

1881. 


Copyright,  1881, 
By  Frederic  Henry  Gerkish. 


University  Press: 
John  Wilson  and  Son,  Cambridge. 


TRANSLATOR'S    PREFACE. 


Although  for  more  than  a  decade  it  has  been  hardly  pos- 
sible to  glance  through  a  medical  journal  without  seeing 
something  concerning  the  Lister  method,  there  are  compara- 
tively few  medical  men  in  this  country  who  have  a  sufficiently 
good  knowledge  of  this  modern  system  of  treating  wounds 
to  enable  them  to  apply  it  with  essential  accuracy.  The 
result  is  that  it  is  either  not  used  at  all  by  most  surgeons, 
or  else  is  incorrectly  employed  with  disappointing  results, 
which  are  not  fairly  attributable  to  the  method.  This  con- 
dition of  affairs  is  probably  largely  due  to  the  fact  that  there 
has  been  no  low-priced  treatise  on  the  subject  in  the  English 
language,  from  which  one  could  acquire  the  necessary  infor- 
mation with  regard  to  the  principles,  practice,  and  results  of 
Antiseptic  Surgery.  With  the  desire  of  supplying  my  fellow 
practitioners  in  America  with  such  a  work,  and  thus  enabling 
them  to  experience  the  benefits  of  a  method  which  will  do 
more  thaij  any  other  to  lead  their  surgical  patients  to  re- 
covery without  delay,  danger,  or  discomfort,  I  have  translated 
this  work  of  an  eminent  French  surgeon.  Its  careful  perusal 
will,  I  believe,  make  it  plain,  not  only  that  the  Listerian 
theory  is  rational  and  its  practice  wonderfully  satisfactory, 
but  also  that  its  application  is  neither  difficult,  nor  seriously 
expensive. 

1 


2  -  PREFACE. 

The  book  is  so  nearly  exhaustive  that  there  has  seemed  to 
me  to  be  need  of  very  little  editorial  work.  A  few  omissions 
of  an  unimportant  character  have  been  made,  among  them 
that  of  the  bibliographical  index,  which  is  confessedly  far 
from  complete,  and  is  quite  unnecessary  to  those  who  have 
access  to  the  published  volume  of  the  Index  Catalogue  of  the 
library  of  the  Surgeon-General's  office,  U.  S.  Army.  In  the 
chapter  on  apjDaratus,  I  have  omitted  the  descriptions  and 
pictures  of  several  foreign  spray-producers,  and  have  intro- 
duced cuts  of  others  which  are  made  in  this  country,  and  can, 
therefore,  be  obtained  more  easily  and  cheaply  than  those  of 
exotic  origin.  For  the  convenience  of  any  who  are  not 
familiar  with  the  metric  system,  a  table  of  equivalents  has 
been  inserted  near  the  end  of  the  book. 

In  a  recent  letter  the  author  enclosed  to  me  a  report 
of  four  cases  of  Porro's  operation,  and  it  is  so  important 
and  interesting  that  I  have  included  it  in  the  nineteenth 
chapter. 

My  own  additions  to  the  work  will  be  found  in  the  foot- 
notes. 

F.  H.  G. 

Portland,  Maine, 

4th  of  July,  1881. 


TO 


JOSEPH    LISTEE, 

PKOFESSOR   or   CLIKICAL   SURGEKT  IN   KING's   COLLEGE   HOSPITAL. 


/  dedicate  the  Second  Edition  of  this  Work  to  you,  in  the  hope 
that  it  may  have  the  same  good  fortune  as  the  First. 

The  purpose  of  the  First  was  particularly  to  malce  "known  the 
principles  and  the  method.  It  succeeded  leyond  my  hopes.  To-day 
Antiseptic  Surgery  is  knoivn  in  France. 

This  new  edition,  much  more  comprehensive,  and  written  with  a 
much  larger  personal  experience,  is  designed  to  teach  more  completely 
the  practice,  and  how  the  resources  of  the  method  may  le  lest  employed. 
I  trust  that  it  loill  enable  all  its  readers  to  ap^neciate  the  great 
progress  which  surgery  owes  to  you. 


CONTENTS. 


PAGK 

Introduction 9 

CHAPTER  I. 

Progress  of  Surgery.  —  Practices  designed  to  defend  Wounds  from 
the  Injurious  Action  of  the  Air,  —  Occlusion  and  Antisepsis  in 
Ancient  and  Modern  Times.  —  The  Method  of  Lister    .     .     .     .     17 

CHAPTER   II. 

Theoretical  Views  on  which  the  Practice  of  the  Dressing  is  based      .     25 

CHAPTER   III. 
The  Practice  of  the  Dressing .     33 

CHAPTER  IV. 

The  Dressing  of  Old  Wounds  which  have,  or  have  not,  Fistules.  — 

Wounds  in  the  Neighborhood  of  Natural  Openings 53 

CHAPTER   V. 
Boracic  Acid  Dressing. — Unirritating  Dressings. — Ununited  Wounds     58 

CHAPTER   VI. 
The  Time  when  the  Antiseptic  Dressing  may  be  omitted      ....     60 

CHAPTER  VII. 
The  Suture  and  Closure  of  Wounds.  —  Superficial  and  Deep  Su- 
tures. —  Compression  with  Carbolized  Sponge 62 

CHAPTER  VIII. 
Drainage 67 


CONTENTS. 


CHAPTER  IX. 

PAGE 

The  Antiseptic  Spray 73 

CHAPTER  X. 

Catgut :   its  Uses  as  a  Ligature,  for  Drainage,  as  a  Suture,  and  in 

the  Plugging  of  Bony  Cavities 83 

CHAPTER  XI. 

Influence  of  the  Method  upon  the  Phenomena  of  Repair.  —  The  Ab- 
sence of  Suppuration.  —  The  Beginnings  of  Experimentation. — 
Absence  of  Micro-organisms 89 

CHAPTER  XII. 

General  Results  of  the  Dressings.  —  Wound  Complications.  —  Some 

Figures.  —  Lister.  —  Saxtorph.  —  Volkmann 104 

CHAPTER  XIII. 
Particular  Operations  and  Dressings.  —  Practice  and  Results.  —  Im- 
mediate Union.  —  Plastic  Operations.  —  Extirpation  of  Tumors 
of  the  Soft  Parts 115 

CHAPTER  XIV. 

Compound   Fractures.  —  Purification.  —  Immobilization.  —  Gunshot 

"Wounds  in  Military  Surgery 119 

CHAPTER  XV. 

Osteotomy.  — •  Rachitic  Curvatures   and  Genu  Valgum.  —  Fractures 

of  Joints.  —  Resection  in  False  Joints 124 

CHAPTER  XVI. 
Amputations  and  Disarticulations 128 

CHAPTER  XVII. 
Accidental  aiid  Operation  Wounds  of  Joints.  —  Removal  of  Foreign 
Bodies.  —  Operations  for  Fractures  and  Dislocations.  —  Opening 
of  .Joints  for  Hydrarthrosis.  —  Opening  of  Diseased  Joints. — 
Opening  of  White  Swellings.  —  Antiseptic  Irrigation  of  In- 
flamed Articulations 132 


CONTENTS.  '7 


CHAPTER  XVIII. 

PAGK 

Resection  of  Joints 143 

CHAPTER  XIX. 
Operations  upon  the  Peritoneum.  —  Strangulated  Hernia.  —  Radical 
Cure  of   Hernia.  —  Umbilical   Hernia.  —  Laparotomy.  —  Ova- 
riotomy. —  Porro's  Operation.  —  Cysts  of  the  Liver      ....  146 

CHAPTER  XX. 

Operations  on  the  Female  Genital  Organs.  —  Operations  with  Perfect 
and  Partial  Asepsis.  —  Obliteration  of  the  Yagina.  —  Vesico- 
vaginal Fistulse  and  Perineorrhaphy.  —  Enucleation  of  Fibrous 
Tumors  of  the  Womb.  —  Aseptic  Parturition 164 

CHAPTER  XXI. 
Ligature  of  Arteries  and  Veins.  —  Radical  Cure  of  Varices  and  Vari- 
cocele   176 

CHAPTER  XXIL 
Treatment  of  Abscesses 180 

CHAPTER  XXIII. 

Empyema.  —  Hypogastric  Lithotomy 185 

CHAPTER    XXIV. 
Castration  and  Operations  on  the  Testicle.  —  Cure  of  Hydrocele  by 

Volkmann's  Method 187 

CHAPTER  XXV. 

Operations  upon  Tendons  and  their  Sheaths.  —  Opening  of  Large 

Cysts.  —  Club-foot.  —  Suture  of  Tendons 189 

CHAPTER  XXVI. 
Trephining  of  the  Skull 190 

CHAPTER   XXVIL 
Treatment  of  Ulcers.  —  Epidermic  Grafting 191 


5  CONTENTS. 

CHAPTER    XXVIII. 

PAGE 

Ophthalmic  Surgery 194 

CHAPTEE    XXIX. 
Influence  of  Listerism  upon  the  Healthfulness  of  Hospitals       .     .     .  197 

CHAPTER    XXX. 
Poisoning  by  Carbolic  Acid.  —  Carbolic  Eczema 200 

CHAPTER    XXXI. 
Objections  to  the  Antiseptic  Method 204 

CHAPTER   XXXII. 

Employment  of  Various    Proceedings   when  the    Elements   of   the 

Antiseptic  Method  fail 212 

CHAPTER   XXXIII. 
Formulse  for  preparing  the  Materials  employed  in  the  True  Lister 

Dressing 214 


APPENDIX. 

Comparison  of  some  of  the  principal  Measures  of  the  Metric  Sys- 
tem with  those  in  common  use.  —  Comparison  of  Therm ometric 
Scales 230 

Index 233 


ANTISEPTIC    SURGERY. 


INTRODUCTION. 

The  first  edition  of  this  book  was  published  not  long  ago, 
and  now  the  progress  of  the  antiseptic  method  is  so  well 
known  that  there  is  no  need  of  long  preliminaries  to  tell  how 
profoundly  it  has  modified,  even  transformed,  the  surgical 
practice  of  our  time. 

The  reception  with  which  it  has  met  has  undoubtedly 
varied:  even  in  England  it  has  difficulty  in  acquiring  the 
position  which  is  its  due  ;  in  Denmark  it  reigns  supreme  ; 
in  Germany  it  has  its  enthusiasts,  since  it  has  undergone 
changes ;  in  Austria,  Switzerland,  Holland,  Russia,  Italy,  and 
America,  we  meet  eminent  representatives  of  Listerian  sur- 
gery ;  and,  indeed,  we  believe  there  is  hardly  a  country 
where  there  are  not  some  ardent  disciples  who  proclaim  its 
merits. 

In  France  it  has  gained  a  firm  foothold,  and,  although  we 
have  had  some  difficulty  in  acclimating  it  in  the  hospitals  of 
Paris,  the  situation  is  such  to-day  that  there  is  small  possi- 
bility of  its  being  deposed. 

2 


10  "'  ANTISEPTIC    SURGERY. 

In  1875,  when,  in  my  hospital  service,  I  myself  provided 
the  materials  for  the  dressing  and  the  necessary  apparatus, 
and  undertook  to  make  the  first  rigorously  precise  appli- 
cation, in  accordance  M^ith  what  I  had  learned  in  Scotland, 
it  met  with  a  discouraging  reception  from  many  of  my  col- 
leagues. 

But  I  had  followed  the  first  steps  of  the  method  since 
1867;  had  seen  it  applied  in  Glasgow  in  1868;  had  described 
it  to  the  French  surgeons  in  January,  1869  ;  had  kept  it 
before  them  in  every  succeeding  year  by  showing  its  progress 
and  by  introducing  into  my  practice,  with  great  success,  the 
employment  of  powerful  antiseptics.  Above  all,  in  1875,  I 
made  at  Edinburgh,  de  visu,  an  exhaustive  study  of  it.  So 
nothing  could  discourage  me  or  deter  me  from  faithfully 
testing  it. 

Soon  some  of  my  colleagues,  struck  by  the  remarkable 
cases  which  I  described  to  them,  and  surprised  by  the  grow- 
ing reputation  of  the  method  abroad,  asked  me  to  teach  them 
the  practice  of  it ;  and  Professors  Guyon  and  Verneuil  were 
the  first  to  be  convinced  by  their  own  experience  of  its 
immense  value. 

It  was  with  difiiculty  that,  even  after  a  year  of  effort,  of 
personal  trouble,  we  prevailed  upon  the  administration  of  the 
hospitals  to  furnish  the  materials  for  the  dressing.  To-day 
they  can  be  had  for  the  asking. 

This  great  step  having  been  taken,  there  was  a  chance  for 
the  propagation  of  the  Lister  method ;  and  I  was  able  to 
introduce  it  into  the  services  of  my  colleagues  and  friends, 
and  those  of  which  I  had  charge,  where  it  reigns  supreme 
to-day. 

In  fact,  for  four  years  I  have  had  a  large  personal  experi- 


INTRODUCTION.  11 

ence  with  the  method,  and  that,  too,  in  varied  services,  in 
widely  different  hospitals,  in  some  of  which  I  found  the  most 
deplorable  sanitary  condition. 

Now,  what  was  this  experience  ?  One  could  tell  it  in  a 
word :  in  the  Paris  hospitals,  and  in  the  worst  of  them,  we 
are  obliged  to  make  the  most  dreaded  operations  ;  we  per- 
form them  with  the  same  sense  of  security  which  we  should 
feel  in  the  country  where  the  air  is  the  most  pure.  We  have 
thus  all  the  outside  advantages  of  the  country,  and  all  the 
facilities  which  can  be  furnished  only  in  a  hospital. 

N^laton,  who  was  esteemed  one  of  the  most  fortunate  of 
operators,  was  accustomed  to  say  that  the  man  who  should 
discover  the  means  of  suppressing  purulent  infection  de- 
served a  statue  of  gold.  If  this  view  of  N^laton's  was  gen- 
erally entertained,  the  statue  would  be  raised  to  Professor 
Lister;  for  purulent  infection  has  disappeared  from  the  list 
of  wound  complications  in  the  services  where  his  method  is 
followed. 

Erysipelas,  if  not  altogether  unknown,  is  infinitely  rare. 
For  four  years,  I  have  not  had  a  single  case  after  my  opera- 
tions ;  and  yet  I  can  truly  say  that,  during  that  time,  I  have 
made  all  the  operations  which  are  most  liable  to  be  followed 
by  this  disease  and  purulent  infection. 

But  this  is  not  all:  security  against  accidents  of  this  nature 
is,  indeed,  the  chief  advantage  of  the  method,  but  the  others 
are  of  great  value. 

The  wonderful  regularity  of  repair  and  the  rapidity  of 
healing  are  two  phenomena  of  the  highest  importance.  Ask 
a  patient  who  has  suffered  amputation  of  the  leg  whether  he 
prefers  to  recover  in  twenty  days  rather  than  in  two  months  ; 
ask  a  woman  whose  breast  has  been  removed  if  she  would 


12  "  ANTISEPTIC    SURGERY. 

like  better  to  be  cured  after  one  or  two  weeks,  or  remain 
from  six  weeks  to  three  months  with  a  gaping  wound,  —  and 
you  will  have  the  response  which  some  surgeons  are  obsti- 
nately bent  upon  not  giving. 

These  facts  are  not  exceptional ;  they  are  the  regular  and 
constant  results  of  this  method  of  procedure,  of  which  we 
ma}''  say  further  that  the  subsequent  suffering  and  the  trau- 
matic fever  are  reduced  to  the  minimum. 

The  wounds  unite  immediately  in  the  greater  part  of  their 
extent,  and  the  remainder  does  not  suppurate. 

All  the  dressings  are  remarkably  neat,  are  required  less 
and  less  frequently  as  a  case  progresses,  and  we  see  disap- 
pearing from  surgery  the  epithems,  the  uncleanness  of  which 
can  only  be  compared  with  that  of  the  pus-covered  wounds 
which  they  were  designed  to  protect. 

The  results  of  this  new  surgery  are  so  remarkable  that 
they  have  attracted  the  attention  of  the  most  incredulous. 
These,  as  is  well  understood,  will  not  allow  themselves  to 
apply  the  Lister  dressing,  but  each  borrows  something  from 
it,  —  perfect  apposition,  drainage,  but,  above  all,  the  use 
of  powerful  antiseptics.  Everything  is  laid  under  contribu- 
tion ;  and  we  see  to-day,  in  all  the  services  in  Paris,  washing 
of  hands,  of  instruments,  and  of  patients  in  carbolized  water, 
—  a  proceeding  formerly  unknown. 

This  kind  of  thing  is  not  the  dressing  of  Lister  ;  and  yet, 
such  is  the  value  of  the  principal  directions  so  clearly  laid 
down  by  him,  that  the  results  of  the  surgery  of  all  these 
imitators  are  already  vastly  improved. 

As  always  happens  in  such  cases,  it  has  been  contended 
that  Professor  Lister  did  not  invent  his  own  dressing;  he  has 
been  accused  of  having  pretended  to   discover  antiseptics ; 


INTRODUCTION.  13 

and  there  are  even  those  who  deny  the  immense  progress 
which  has  come  from  ascertaining  the  effects  of  necessary 
doses  of  these  antiseptics. 

Have   we  not  seen  a  comparison  instituted  between  the 
dressing  of  Lister  and  that  of  Azam,  of  Bordeaux?     Is  it 
possible  to  compare  the  dressing  of  Azam,  which  is  substan- 
tially only  the  partial  apposition  in  the  stumps  after  amputa- 
tion, together  with  drainage  (an  affair  already  known),  with 
a  method  like  that  under  consideration,  which  at  once  in- 
flamed  the   surgical   world?     It  is  well  to  remember,   too, 
that  all  publication  upon  the  Azam  dressing  was  subsequent 
to  the  announcement  of  the  Lister  method,  and,  better  still, 
that  Azam  has  never  laid  claim  to  it  at  all.     With  the  great- 
est frankness,  in  publishing  the  very  remarkable  results  of 
his  practice,  he  made  known  the  names  of  the  surgeons  who 
brought  to  Bordeaux  the  elements  of  the  amputation  dress- 
ing:   Labat,  the   deep  drain;    Dudon,  the    double    suture; 
Denuc^,  the  perfecting  of  the  superficial  suture  ;  and,  more- 
over, each  of  these  elements  existed  before  this  dressing. 

Doubtless  the  cause  of  these  quarrels  is  that  the  surgical 
world  still  considers  the  dressing  of  Lister  as  a  procedure, 
instead  of  comprehending  the  fact  that  it  is  a  method.' 
Any  one  who  has  attentively  studied  or  experimented  could 
not  make  a  mistake  upon  this  point.  Whoever  has  followed 
a  service  where  the  antiseptic  method  is  rigorously  carried 
out  must  have  been  struck  by  the  fundamental  difference  in 
the  mode  of  repair  of  wounds.  It  is  no  longer  a  question  of 
the  more  or  less  perfect  healing  after  a  particular  operation  ; 
but  all  surgery  is  affected. 

When   one  has  seen  wounds  heal  without  suppuration  ; 
abscesses,  as  soon  as  evacuated,  dry  up  and  close  rapidly;  the 


14  ANTISEPTIC    SUEGEEY. 

great  joints,  when  opened,  allow  themselves  to  he  roughly 
handled  without  resenting  it ;  clots  of  blood,  instead  of  inter- 
fering with  repair,  contribute  to  its  perfection,  —  he  compre- 
hends that  a  new  element  has  entered  into  surgery.  It  is 
not  a  question  o*f  comparing  one  dressing  with  others,  of 
making  a  distinction  between  various  topics.  It  is  neces- 
sary to  find  out  by  experience  whether  the  advocates  of  the 
method  have  stated  facts,  or  have  allowed  themselves  to  be 
lured  away  by  the  promise  of  novelty. 

When  we  hear  it  said  that  this  method  is  a  matter  of 
interest  only  in  the  great  cities,  in  centres  of  infection,  we 
regret  that  it  is  not  better  understood.  Doubtless  it  is  in 
the  hospital,  and  the  very  worst,  that  it  attains  the  highest 
degree  of  interest ;  for  it  succeeds,  in  a  way,  in  making  the 
place  healthy.  But  much  more  than  this:  it  has  so  trans- 
formed surgery  that  its  employment  is  called  for  every- 
where. Perchance,  in  exceptionally  favorable  conditions, 
one  may  omit  some  parts  of  the  dressing  which  are  indis- 
pensable in  bad  surroundings ;  but  the  ensemble  of  the 
method  must  remain,  and  is  demanded  in  the  country  as  well 
as  in  town.  Certain  operations  are  justifiable  only  under  its 
protection. 

Whatever  has  been  the  progress  of  modern  surgery,  the 
antiseptic  method  came  at  a  time  when  the  surgeon,  often 
disarmed  by  surgical  complications,  saw  his  horizon  limited 
by  cruel  uncertainties.  It  was  impossible  to  predict  the 
results  of  operation,  and  security  was  so  imperilled  that  cer- 
tain conditions  appalled  the  boldest,  and  certain  operations 
were  practically  prohibited  to  the  surgeons  of  cities,  who, 
even  though  consummately  skilful,  found  themselves  unable 
to  produce  results  equal  to  those  of  their  far  from  expert 


INTEODUCTIOlSr.  15. 

brethren  in  the  country,  where  the  atmosphere  is  untainted. 
The  antiseptic  method  came,  and  gave  an  impetus  to  surgery, 
for  it  provided  skill  with  means  of  success. 

This  new  power  of  surgery,  it  seems  to  me,  can  be  acquired 
only  by  faithful  disciples,  as  I  shall  "explain  further  on. 
Approximations  to  antiseptic  surgery,  and  attempts  at 
imitating  it,  have  everywhere  ended  in  cruel  disappoint- 
ment. 

Therefore,  I  have  refrained  from  explaining  in  this  work 
the  modifications  of  the  method  which  have  been  suggested, 
although  I  have  studied  them  and  know  that  some  of  them 
are  of  interest.  Contrary  to  what  has  been  said,  I  believe 
this  surgery  to  be  within  the  reach  of  all  the  world;  I  believe 
that  every  one  may  be  so  convinced  that  he  will  not  deviate 
from  the  rules  which  have  been  laid  down.  But  one  can 
easily  understand  that,  until  it  is  acknowledged  as  a  matter 
of  surgical  duty,  only  a  small  number  will  rigorously  follow 
the  necessary  practice  and  attain  satisfactory  results. 

For  my  part,  I  write  the  new  edition  of  this  work  to-day 
with  a  very  different  personal  experience  from  that  of  four 
years  ago.  Whatever  I  state,  I  have  tried  and  observed.  I 
have  educated  myself  upon  all  these  points,  and,  confident  of 
success,  I  have  fearlessly  performed  operations  which  for- 
merly one  would  scarcely  have  ventured  on. 

I  assert  more  emphatically  than  ever  that  we  can  do  no 
better  than  to  remain  faithful  to  the  words  of  the  master  ; 
and  that  I  may  deserve  to  be  considered  elsewhere,  as  I  am 
already  in  the  Surgical  Society,  his  apostle,  I  promise  those 
who  shall  obey  them  the  following  things :  — 

The  disappearance  of  wound  accidents  even  in  the  worst 
circumstances. 


16  ANTISEPTIC    SURGERY. 

A  regularity  in  repair  hitherto  unknown. 
Surgery  without  suppuration. 

Union  bj^  first  intention  habitually  and  without  danger. 
Such  rapidity  in  healing  as  to  surpass  all  anticipation. 
The  possibility  and  safety  of  operations  hitherto  considered 
dangerous  and  even  unjustifiable. 

This  is  no  vain  promise,  for  these  results  are  obtained 
daily,  and  we  may  be  allowed  to  say  with  satisfaction  that 
our  efforts  ar^  crowned  i^dth  success.  A  few  years  ago  the 
hospitals  of  Paris  were  reckoned  among  the  worst,  even  by 
the  verdict  of  some  of  their  own  surgeons.  To-day  their 
surgery  is  as  fortunate  as  that  anywhere  in  the  world.  Even 
the  Csesarean  operation  is  successful. 


CHAPTER  I. 

Pkogress  of  Surgery. — Practices  designed  to  protect  Wounds 
FROM  THE  Injurious  Action  of  the  Air  ;  Occlusion  and  Anti- 
sepsis IN  Ancient  and  Modern  Times.  —  The  Method  of 
Lister. 

Habdly  any  advance  has  been  made  in  natural  science  with- 
out its  having  been  remarked  that  discoveries  of  the  same 
kind  preceded  the  announcement  of  the  modern  achieve- 
ments. This  is  explained  by  the  fact  that  in  the  sciences 
which  depend  upon  observation,  the  conditions  of  experimen- 
tation are  so  complex,  so  disturbed  by  circumstances  of  every 
kind,  that  one  cannot  know  at  once  all  the  elements  of 
progress.  He  must  advance  when  he  catches  sight  of  the 
truth,  retrace  his  steps  when  certain  circumstances  conceal 
it  from  him,  then  advance  again  and  take  a  longer  and  surer 
step,  because  all  previous  experience  is  pointing  out  the  way 
to  him. 

The  antiseptic  method  followed  the  usual  course :  it  did 
not  come  complete  from  the  brain  of  one  man  ;  it  would  be 
incorrect  to  say  that  it  burst  suddenly  upon  surgery  like  a 
revelation.  The  eminent  savant  who  has  formulated  with 
so  much  care  the  minutest  directions  concerning  it  does  not 
deny  this,  nor  does  any  one  of  his  devoted  followers. 

If  we  go  back  to  the  earliest  history  of  surgery,  we  find 
the  idea  of  the  harmful  effect  of  the  admission  of  air  to 
solutions  of  continuity  in  the  human  body.  In  studying  the 
history  of  surgery,  we  are  continually  catching  sight  of  the 
constant  struggle   of  art  with   this   action,  —  an   empirical 


18  ANTISEPTIC    SURGERY. 

struggle,  now  abandoned,  now  renewed  with  ever  increasing 
success. 

Two  principal  processes  have  constituted  the  elements  of 
this  struggle,  —  the  occlusion  of  wounds,  and  antisepsis,  which 
we  venture  to  believe  was  unconscious. 

Occlusion  is,  theoretically,  the  simplest  method  of  protect- 
ing wounds  from  the  action  of  the  air ;  practically,  it  is  the 
most  complicated.  We  find  the  beginning  of  its  history 
among  savages  who  cover  their  wounds  with  sand  or  mud, 
and  think  that  their  recovery  is  facilitated  by  this  process. 

Two  dates,  celebrated  in  the  history  of  occlusion,  ought  to 
be  especially  marked  by  two  names,  Magatus  and  Larrey. 
Magatus  in  1616  not  only  briefly  formulated  the  directions 
for  occlusion,  but  wrote  an  account,  marvellous  for  the  age, 
of  the  theories  of  traumatic  fever  and  of  septicaemia. 

Larrey,  with  his  great  military  experience,  afterwards 
introduced  a  valuable  method  which  contrasted  with  the 
recognized  practice,  and  shocked  the  ideas  of  his  contempo- 
raries, but  saved  many  lives.  In  employing  infrequent  dress- 
ings, he  acted  empirically,  guided  by  his  wonderful  clinical 
instinct.  In  spite  of  his  natural  desire  to  inspect  the 
wounds,  in  spite  of  the  dreadful  odor  emitted  by  the  pus- 
saturated  dressings,  he  persisted  in  his  practice  and  obtained 
remarkable  results.  In  analyzing  these  results,  we  find 
points  which  are  difficult  to  explain  ;  yet  we  have  a  begin- 
ning of  the  interpretation  in  the  science  of  the  infinitely 
little. 

In  our  modern  surgery  we  find  a  multitude  of  occlusion 
processes.  Each  of  these  has  been  thought  to  deserve  the 
name  of  a  new  method,  according  as  it  was  more  or  less 
complicated,  more  or  less  ingenious.  In  all  of  these  methods 
there  was  a  common  principle,  Avhich  explains  their  success : 
they  prevented  the  circulation  and  stagnation  of  air  in  and 


OCCLUSION    PROCESSES.  19 

about  the  wounds,  perhaps  simply  by  isolation,  perhaps  by 
exhaustion  of  the  air  and  the  altered  fluids. 

Serious  difficulties  of  application  prevented  the  continuance 
of  these  methods,  excepting  the  wadded  dressing  of  Alphonse 
Gudrin,  which  has  rendered  services  so  remarkable,  although 
this  eminent  surgeon  made  it  known  only  a  few  years  ago 
(1871).  This  does  not  exclude  the  air,  as  the  occlusion 
dressings  pretended  to  do,  but  filters  it,  and  consequently 
renders  it  harmless  to  the  wounded  organism.  It  fulfils  yet 
other  conditions,  which  are  of  less  importance  but  advanta- 
geous to  wounds,  and  constitutes  one  of  the  most  powerful 
methods  in  surgery.  We  hasten  to  add  that  it  is  no  longer 
an  empirical  dressing,  but  is  based  upon  a  serious  scientific 
theory  of  the  accidents  of  wounds,  and  is  now  always  com- 
bined with  antiseptic  precautions. 

Ancient  empiricism  combated  the  harmful  action  of  the 
air  by  proceedings  much  more  powerful  than  the  occlusion  of 
wounds.  There  seems  to  have  been  a  constant  effort  to 
change  the  injured  surfaces,  so  as  to  avoid  the  immediate 
results  of  the  fermentation  and  putrefaction  of  dead  parts 
and  organic  fluids.  The  instruments  by  which  the  modifica- 
tion was  produced  were  various :  the  actual  cautery,  boil- 
ing liquids,  above  all,  antiseptic  substances  have  played  the 
chief  part  in  the  treatment  of  wounds. 

Modern  surgery  has  erred  in  not  holding  in  greater  esteem 
the  prescriptions  of  the  ancients,  and  in  not  admitting  that  so 
remarkable  observers  could  not  have  acted  without  discern- 
ment, and  without  depending  upon  the  mighty  facts  of 
experience. 

What  do  we  see,  in  glancing  through  the  surgical  phar- 
macopoeia, if  not  the  constant  employment  of  powerful  anti- 
septic substances  ?  Undoubtedly,  man  does  not  correctly 
interpret  his  own  actions  ;  undoubtedly,  superstitious  prac- 


20  ANTISEPTIC    SURGERY. 

tices  induce  surgeons  to  put  together  substances  which  are 
more  or  less  extraordinary,  such  as  serpents,  earthworms, 
and  human  fat.  But,  although  in  his  opinion  the  effect  of 
these  substances  is  largely  due  to  their  supernatural  power, 
he  takes  good  care  not  to  use  them  alone ;  he  always  unites 
them  with  antiseptics. 

These  are  manufactured  products,  such  as  turpentine,  wine, 
brandy,  alum,  common  salt,  etc.,  and  many  vegetable  sub- 
stances, among  which  we  find  aloes,  the  leaves  and  shell  of 
the  walnut,  figs,  and  many  other  substances  quite  as  valuable. 

Cataplasms  even  are  of  infinite  variety,  and  contain  antisep- 
tic, aromatic,  and  other  substances.  It  is  only  in  our  time 
that  a  panacea  has  been  found  in  linseed  pulp,  a  fetid  topic 
and  natural  receptacle  of  all  injurious  organisms. 

Surgeons  do  not  even  neglect  the  atmosphere,  for  they 
advise  the  employment  of  aromatic  substances,  and  disin- 
fectants suitable  for  the  fumigation  of  the  sick-chamber. 

The  most  ridiculous  and  mysterious  of  their  formulas,  after 
all,  depend  only  for  their  activity  on  antiseptics,  often  com- 
bined with  oily  substances  which  serve  as  vehicles  and  to 
isolate  the  wounds. 

The  famous  oil  of  puppies,  the  secret  of  which  cost  Am- 
broise  Par^  two  years  of  entreaty,  was  only  a  mixture  of  oil, 
brandy,  and  turpentine,  in  which  living  puppies  and  earth- 
worms played  the  necessary  rdle  of  mystery. 

The  commander's  balsam,  an  alcoholic  compound  of  ben- 
zoin, is  a  type  of  the  antiseptic  substances,  and  its  employ- 
ment has  recently  been  recommended  anew. 

At  a  more  modern  date,  and  in  the  most  classic  works,  we 
also  find  prescriptions  as  neat  as  this  of  Dionis :  "  Oily  and 
putrid  remedies  are  of  no  use  in  wounds  of  the  head ;  the 
balsams  and  spirits  are  there  of  the  most  advantage,  for 
which  one  ought  to  keep  white  balm  and  spirit  of  wine." 


UNCONSCIOUS    ANTISEPSIS.  21 

If  we  go  from  medical  works  to  the  histories  of  chivalry,  in 
which  there  is  no  lack  of  recipes  for  infallible  balms,  we  again 
find  the  employment  of  antiseptics. 

Since  the  confidence  inspired  by  these  substances  has  con- 
tinued for  ages,  it  is  probable  that  they  have  some  real  action, 
that  their  reputation  is  partly  deserved,  and  it  is  surprising 
that  surgery  should  all  at  once  have  the  vanity  to  say,  "  Our 
fathers  were  entirely  mistaken  ;  "  and  henceforth  surgery  is 
done  with  lint,  cerate,  linseed-meal  poultices,  and  hot  and 
cold  water. 

Is  it  necessary  to  attribute  this  abrupt  change  largely  to 
the  influence  of  physiologism,  to  the  doctrine  of  inflamma- 
tion, to  the  work  of  men  whom  Velpeau  called  antiphlogis- 
tiqueurs,  even  while  he  was  constantly  under  their  influence  ? 

However  it  may  be,  the  reaction  has  come  about,  and  is  to 
be  explained  first  and  foremost  by  an  empirical  return  to  anti- 
septics. A  great  number  of  substances  of  recent  production 
have  been  extolled,  and  everybody  has  been  able  with  reason 
to  praise  the  favorable  influence  of  a  new  dressing.  Carbolic 
acid,  an  entirely  modern  production,  has  been  recommended 
by  many.  We  have  seen  several  surgeons  employ  carbolic- 
acid  dressings,  freely  using  weak  solutions  of  it,  and  also, 
what  is  still  more  important,  sprinkling  carbolized  water 
about  for  the  purpose  of  counteracting  the  poison  of  wounds. 
By  these  means  the  wounds  heal  more  rapidly,  and  the 
healthfulness  of  the  wards  is  improved. 

But  alcohol  has  attracted  the  most  attention.  Ardently 
advocated  by  Batailld  and  Le  Cceur,  this  dressing  had  the 
good  fortune  to  be  adopted  by  Ndlaton.  Bataill^  saw  in  it 
the  final  suppression  of  purulent  infection.  Le  Coeur,  with 
his  dressing,  actually  returned  to  the  ancient  practice,  recom- 
mending with  the  alcohol  much  neglected  articles. 

This  dressing  had  an  advantage  over  others  in  being  based 


22  ANTISEPTIC     SUKGEKY. 

upon  a  theory  which  was  revived  by  Neudorfer  some  years 
afterwards  for  carbolic  acid.  Alcohol  coagulates  albuminoid 
substances,  and  makes  them  imputrescible  ;  it  contracts  the 
minute  blood-vessels,  and  renders  them  incapable  of  absorp- 
tion. 

Whatever  there  may  be  defensible  in  this  explanation, 
there  has  been  rapid  progress  in  this  modern  period.  All 
antiseptics,  from  pure  alcohol  to  dilute  caustics,  have  been 
employed  with  varying  success,  but  always  with  success. 

We  have  seen,  then,  substances  w^hich  were  formerly 
thought  to  be  irritant  come  into  ordinary  surgical  use, 
hastening  and  insuring  the  healing  of  wounds  instead  of 
retarding  it. 

Doubtless  the  action  of  each  dressing  was  capable  of  an 
explanation,  but  sufficient  evidence  was  not  adduced  to  estab- 
lish it.  It  was  thought  that  some  modified  the  wound,  that 
others  acted  upon  the  secretions,  that  others  afforded  protec- 
tion from  the  action  of  the  air.  It  was  easy  to  see  that  great 
progress  had  been  made,  for  surgery  was  already  much  im- 
proved ;  but  it  Avas  difficult  to  give  the  reason. 

Furthermore,  success,  though  actual,  was  far  from  being 
constant.  Although  accidents  were  less  frequent  and  the 
progress  of  repair  was  more  regular,  still  with  the  failures 
astonishing  discrepancies  were  observed,  which  the  theories 
previously  advanced  did  not  explain. 

Antiseptic  surgery,  with  its  constant  achievements  and  its 
scientific  interpretations,  begins  a  new  period,  marks  an 
important  triumph.  The  regularity  of  the  work  of  repair, 
almost  without  regard  to  tissues  and  media,  bringing  all 
points  of  the  economy  under  a  common  law,  is  what  chiefly 
attracts  the  attention  of  the  observer. 

The  method  which  Professor  Lister  has  taught  since  1866 
is  evidently  connected  with  the  great  progress  which  we 
record. 


THE   LISTER   METHOD.  23 

This  surgeon  protects  the  organism  against  the  hurtful 
action  of  the  air,  at  least  against  those  parts  of  it  which  are 
poisonous. 

He  gives  the  theory  of  the  action  of  antiseptics. 

He  directs  and  assures  the  regular  course  of  repair. 

He  imparts  to  the  organic  elements  their  greatest  possible 
reparative  power,  by  removing  everything  which  he  had  ascer- 
tained to  be  obstructive  to  their  functions  of  renewal. 

Physiological  study,  we  may  say,  of  the  healing  wound 
agrees  with  the  theoretical  ideas  which  he  has  advanced  as 
necessary  conditions.  In  my  opinion,  this  will  be  the  true 
criterion  of  the  value  of  the  method,  and  of  the  importance  of 
the  discoveries  to  which  it  will  give  birth. 

The  method  of  Lister  is  an  immediate  result  of  the  dis- 
coveries of  Pasteur.  This  eminent  savant  explained  the 
cause  of  the  injuriousness  of  the  air.  He  showed  that  fermen- 
tation is  impossible  in  pure  air.  But  at  the  same  time  he 
demonstrated  that  everywhere  air  is  impure  ;  that  it  is  sur- 
charged with  germs  in  densely  populated  localities  ;  that  the 
number  of  germs  is  less  in  country  places  ;  and  that  when  we 
come  to  the  summits  of  high  mountains  the  scarcity  of  germs 
is  remarkable,  but  still  there  are  germs. 

Now,  according  to  Lister,  as  we  shall  see  later,  it  is  not  the 
air  itself  which  is  hurtful  to  wounds,  but  the  germs  in  the  air 
are  the  source  of  their  putrefaction  and  infection,  and  the 
cause  of  accidents. 

It  is  still  very  difficult  to  explain  the  exact  mechanism  of 
these  accidents.  But  the  researches  of  Pasteur  and  his 
pupils,  of  Davaine,  of  Lister,  of  Bert,  of  Tyndall,  have 
awakened  the  study  of  the  evolution  of  germs  in  infectious 
maladies,  septicaemia,  pyaemia,  and  even  puerperal  fever. 
The  pursuit  of  the  micro-organisms,  to  use  Sedillot's  happy 
expression,   is   made   every   day,    and  every  day    we   study 


24  ANTISEPTIC    SUEGEEY. 

more  accurately  the  conditions  of  their  existence  and  re- 
sistance. 

We  are  beginning  to  understand  that,  in  the  microcosm  of 
the  vibrios,  all  the  beings  are  not  equally  baleful ;  how  it  is 
that  the  appearance  of  certain  of  them  coincides  with  the  dis- 
appearance of  certain  others  ;  how  the  presence  of  fresh  air, 
frequently  renewed  upon  a  denuded  surface,  is  less  favorable 
to  their  development  than  a  dressing  which  imperfectly  covers 
a  wound. 

We  have  seen  that  certain  substances,  employed  as  topics 
and  called  antiseptics,  arrest  the  evolution  and  the  multipli- 
cation of  these  germs. 

We  already  explain  the  apparent  inconsistencies  of  the 
theory  and  the  practice.  We  know  how  dressings  as  different 
as  the  wadded,  the  antiseptic,  and  even  the  open  dressing  act 
in  the  same  direction  ;  it  is  by  the  total  or  partial  destruction 
or  sterilization  of  micro-organisms.  And  although  the  germ 
theory  leaves  so  many  points  to  be  studied,  so  many  obscuri- 
ties to  be  lighted  up,  it  certainly  draws  a  decided  confirma- 
tion from  the  practices  and  theories  of  modern  surgery. 

Science  advances  ;  till  now  we  have  destroyed  the  germ 
without  seeing  it,  almost  without  knowing  it.  Thanks  to 
modern  observers,  we  have  caught  the  vibrio  in  the  process  of 
evolution  ;  we  study  it,  and  every  day  new  proofs  are  added 
to  the  experiences  upon  which  are  based  the  theory  of 
the  harmfulness  of  the  air  and  the  practice  of  antiseptic 
.surgery. 


CHAPTER  II. 

Theoretical   Views   on   which   the   Practice  of  the  Dressing 
•      IS  based. 

The  antiseptic  method  is  founded  upon  a  certain  number  of 
theoretical  ideas,  of  which  the  first  and  most  important  is  that 
of  the  existence  of  germs. 

It  was  in  hospital  practice,  among  the  perpetual  failures  of 
surgery  in  a  thoroughly  infected  hospital  (Glasgow),  that 
Lister  conceived  the  idea  of  the  method  which  has  made  him 
so  famous.  He  had  struggled  ceaselessly  and  in  every 
possible  way  with  insalubrity,  and  was  constantly  vanquished 
by  its  fatal  influences. 

Persuaded  that  the  atmosphere  about  the  wounded  is 
especially  pernicious  in  its  effects,  he  thought  that  these 
should  be  attributed  to  the  numerous  germs  which  Pasteur 
was  studying  in  all  the  media  which  surround  us.  He  be- 
came a  convert  to  the  doctrines  of  the  eminent  French, 
chemist.  This  was  in  1865,  —  that  is,  a  short  time  after  the 
first  publications  of  that  illustrious  experimenter.  Lister 
made  for  himself  numerous  experiments  which  demonstrated 
the  presence  of  germs  in  the  atmosphere,  and  their  influence 
upon  fermentation  and  putrefaction,  and  then  proposed  to 
enter  into  a  struggle  with  the  disturbing  elements.  The 
atmospheric  germs,  he  said,  provoke  suppuration  ;  they  ex- 
cite putrefaction  of  the  blood  and  other  animal  fluids,  and, 
by  this  process,  produce  complications  in  wounds. 

Thus  the  germs  or  microzymes  are,  according  to  him,  the 
cause  of  the  infectious  accidents  of  wounds ;  and,  if  they  are 

3 


26  .  ANTISEPTIC    SURGERY. 

destroyed,  if  their  development  is  prevented,  we  shall  be 
guarded  against  the  complications  which  harass  surgery. 

The  germs,  like  the  vibrios  which  they  engender,  are  infi- 
nitely varied  :  all  are  not  equally  harmful ;  it  is  even  certain 
that  there  are  some  which  destroy  those  more  harmful  than 
themselves.  But  they  exist  always  in  the  atmosphere,  de- 
posited upon  the  surface  of  all  objects,  and  especially  in  all 
putrefied  and  putrescible  matters  which  remain  on  the  instru- 
ments, the  hands,  and  the  pieces  of  dressing. 

It  being  impossible  to  discriminate  between  the  good  and 
the  bad,  the  surgeon  should  seek  the  suppression  of  all.  The 
direct  or  indirect  destruction  of  all  these  living  beings  and  of 
all  germs  has  been  practised  by  Lister. 

The  result  has  been  the  disappearance  of  the  accidents  of 
wounds  ;  he  has  seen  purulent  infection  and  hospital  gangrene 
absolutely  put  to  flight.  Hospitalism  is  no  longer  a  cause  of 
mortality. 

The  ensemble  of  conditions  practically  necessary  to  the  dis- 
appearance of  the  germs  put  the  wounds  into  a  peculiar  state, 
and  little  by  little  Lister  was  led  to  study  exhaustively  the 
conditions  of  their  repair.  He  very  soon  saw  that  to  insure 
the  healthiness  of  wounds  not  only  must  the  micro-organisms 
be  kept  away,  but  it  was  also  necessary  to  study  certain  con- 
ditions which  are  favorable,  even  essential,  to  the  regularity 
of  the  reparative  process,  if  one  wished  to  achieve  more  per- 
fect surgical  results. 

These  conditions  are  subordinate  in  comparison  with  the 
prime  importance  which  must  attach  to  the  destruction  of 
germs,  but  yet  they  play  a  prominent  part  in  practice. 

When  the  conditions  are  most  favorable  to  the  repair  of 
tissues,  as  in  subcutaneous  injuries,  there  is  no  suppuration. 
Contrary  to  many  of  the  received  ideas,  it  must  be  admitted 
that  suppuration  is  not  a  necessary  phenomenon.     It  implies 


CAUSES    OF    SUPPURATION.  27 

a  difficulty,  an  obstacle  to  repair.     It  appears  when  the  vital 
ity  of  the  newly  formed  elements  is  lowered.     It  is  necessary 
to  seek  for  the  cause  of  the  irritation  which  is  produced,  the . 
source  of  the  trouble.     Lister  recognized  the  fact  that  three 
conditions  produce  this  untoward  result :  — 

Excessive  tension  in  the  tissues. 

Direct  irritation  of  the  living  tissues,  and  the  presence  of  a 
foreign  body. 

Direct  irritation  hy  the  atmosphere  charged  with  germs. 

What  is  excessive  tension  ?  It  is  the  phenomenon  accom- 
panying all  local  inflammations,  liable  to  lead  to  suppuration. 
In  a  phlegmon,  in  a  dropsy,  in  a  considerable  effusion  of 
blood,  there  is  excessive  tension. 

Leave  an  abscess  to  itself  in  the  process  of  formation,  and 
you  see  this  excessive  tension  develop  and  increase  without 
cessation.  Suppuration  advances  and  continues  even  to  the 
point  of  solution  of  continuity.  Penetrate  to  the  purulent 
layer,  reach  the  abscess  and  evacuate  it :  it  ceases  to  advance  ; 
the  tension  disappears ;  and  one  of  the  causes  of  suppuration 
is  removed.  Then  the  others  show  themselves ;  but  if  you 
can  arrest  your  disease  at  that  point,  you  will  see  the  suppu- 
ration dry  up  with  remarkable  rapidity.  The  opening  of  the 
abscess  with  the  precautions  of  the  antiseptic  method  serves 
to  show  the  truth  of  this  theoretical  view. 

We  have  another  distinct  illustration  in  the  accumulation 
of  serum  beneath  flaps  which  have  united  by  first  intention. 
Close  wounds  hermetically  and  let  liquid  accumulate,  and  a 
focus  of  suppuration  will  be  formed  behind  the  flap.  If  the 
wound  is  in  a  region  liable  to  infiltration,  in  the  scalp,  for 
instance,  there  is  the  starting  point  of  an  immense  phlegmon. 
The  retention  of  fluid  may  be  the  sole  cause.  Therefore  the 
draining-off  of  superabundant  fluids  should  always  be  pro- 


28     .  ANTISEPTIC    SURGERY. 

moted  by  all  possible  means,  and  the  method  of  Professor 
Lister  pre-eminently  fulfils  this  indication. 

Another  disturbing  cause  of  no  less  importance  is  direct 
irritation.  Apply  permanently  to  the  surface  of  a  wound  an 
irritating  or  caustic  substance,  and  you  will  see  a  purulent 
secretion  form.  Mortification,  wholly  superficial  though  it 
be,  will  induce  the  immediate  throwing-off  of  the  parts. 
Then,  if  the  irritation  continues,  granulation  takes  place. 
The  granulations  being  irritated  give  rise  to  suppuration. 

One  can  observe  these  facts  easily.  If  we  inject  irritants 
into  subcutaneous  wounds,  which,  left  to  themselves,  would 
not  suppurate,  they  do  suppurate  on  the  principle  of  irrita- 
tion. If  an  external  wound,  although  it  be  absolutely  aseptic, 
absolutely  secure  against  the  contact  of  germs  and  atmos- 
pheric products,  is  dressed  with  an  irritating  substance,  it 
necessarily  suppurates.  If  the  use  of  the  irritant  is  continued, 
the  wound  becomes  granular,  the  granulations  suppurate. 
The  granulation  was  no  more  a  necessary  phenomenon  of 
repair  than  was  the  suppuration. 

The  irritant  substance  may  be  a  foreign  body.  Neverthe- 
less, if  this  foreign  body  has  no  direct  irritant  action  upon  the 
living  parts,  if  it  is  absolutely  aseptic,  that  is  to  say,  unaccom- 
panied by  germs,  it  can  interfere  in  no  wise  with  the  phenom- 
ena of  repair,  and  will  permit  normal  action  to  go  on  all 
around  it,  of  which  we  shall  give  examples  when  speaking  of 
ligatures  which  are  enclosed  in  wounds. 

We  come  now  to  the  last  condition,  the  basis,  the  chief 
point  in  the  theory  of  suppuration,  —  the  influence  of  germs. 
Let  us  imagine  a  wound  without  excess  of  tension,  without 
local  irritation,  without  a  foreign  body.  If  atmospheric  germs 
are  deposited  upon  this  wound,  it  will  suppurate.  It  is  not 
the  action  of  the  air  itself  which  induces  this  suppuration  ;  for, 
if  we  make  the  atmosphere  strictly  aseptic,  entirely  free  from 
germs,  the  wound  will  not  suppurate. 


PUTREFACTION   FROM   GERMS.  29 

Doubtless,  the  purer  the  air  becomes,  the  less  harmful  is  it 
to  a  wound ;  but  it  must  be  perfectly  deprived  of  germs 
before  it  can  absolutely  cease  to  be  a  cause  of  suppuration. 
The  surgeon  should  be  thoroughly  convinced  of  the  truth 
of  the  germ  theory.  As  the  eminent  Edinburgh  professor 
has  picturesquely  remarked,  he  ought  to  see  germs  in  the 
atmosphere  as  one  sees  birds  in  the  air. 

There  is  a  great  difference  between  this  cause  of  suppura- 
tion and  the  others  that  we  have  mentioned.  On  this  ac- 
count we  should  be  very  careful  not  to  put  them  upon  the 
same  plane  ;  we  should  put  forward  the  germ  theory  as  the 
pivotal  point  of  the  antiseptic  method. 

Germs  have  a  double  action  :  they  do  not  simply  excite 
the  formation  of  pus,  they  induce  putrefaction  ;  they  deter- 
mine the  putrefaction  of  animal  fluids,  and  thus  they  are  the 
agents  of  wound  complications,  especially  of  the  most  formi- 
dable, pyaemia. 

There  are  great  differences  in  the  nature  of  the  suppura- 
tion excited  by  the  first  causes  mentioned,  and  that  which 
results  from  the  access  of  germs  to  wounds,  which  led  Pro- 
fessor Lister  to  say,  that  in  the  last  case,  the  wound  is 
infected,  that  putrefaction  has  set  in. 

In  the  first  case,  suppuration  is  localized  at  the  defective 
point,  at  a  point  of  suture,  or  at  an  angle  of  the  wound. 
Sometimes  the  pus  is  pent  up,  sometimes  a  little  viscid, 
usually  not  abundant.  The  pus  corpuscles  are  granular,  dis- 
torted. The  dressing  sometimes  has  a  heavy  odor,  but  it 
does  not  have  that  of  putrefaction. 

If  we  suppress  the  cause,  if  we  relieve  pressure  at  the  point 
where  the  fluids  are  retained,  if  we  avoid  the  employment  of 
an  irritant,  and  order  is  restored,  suppuration  disappears. 
With  it  immediately  disappear  the  febrile  symptoms  which 
accompanied  it.     The  case  of  the  retention  of  fluids  is  espe- 


30  ANTISEPTIC    SURGERY. 

cially  remarkable  in  this  regard,  —  that  the  changing  of  a  tube 
or  the  removal  of  a  stitch  is  sufficient  to  modify  both  the  general 
and  the  local  state.  I  have  been  amazed  at  the  appearance 
of  a  drop  of  concealed  pus  ;  but  this  having  been  evacuated, 
order  is  completely  restored. 

But  if  germs  have  had  access,  if  the  dressing  is  infected, 
the  conditions  are  entirely  different.  The  whole  wound  is 
affected,  pus  invades  it,  —  common,  laudable  pus  ;  and  the 
dressing  which  is  bathed  in  it  has  acquired  an  offensive, 
putrid  odor.  Whatever  we  do  now,  suppuration  will  con- 
tinue, healing  will  be  by  granulation,  and  the  rapid  repara- 
tive process  of  the  antiseptic  method  is  lost.  Almost  all 
means  will  be  of  no  avail  to  restore  the  wound  to  its  original 
aseptic  condition.  I  say  almost  all  means,  because  we  shall 
see  further  on  that,  by  certain  contrivances,  we  have  come  to 
employ  the  antiseptic  method  in  the  treatment  of  wounds 
which  have  suppurated,  in  fistulse,  etc.  Up  to  this  point  it 
has  been  my  endeavor  to  indicate  the  progress  of  the  phenom- 
ena and  the  theory  which  explains  them  in  the  case  of  a 
wound  made  by  the  surgeon,  where  the  diseased  part  has  been 
restored  with  unbroken  skin. 

In  all  wounds  which  have  been  exposed  to  the  air  for  some 
time  there  exist  granulations,  the  favorite  lairs  of  microscopic 
organisms  in  all  stages  of  development. 

In  order  that  these  wounds  may  be  put  into  the  condition 
of  fresh  wounds,  and  rendered  susceptible  to  the  same  modi- 
fying influences,  their  surfaces,  their  granulations,  must  be 
destroyed  ;  next,  the  cavities  where  they  lie  must  be  made 
healthy  by  means  of  powerful  antiseptics  ;  and  then,  perhaps, 
it  may  be  possible  to  treat  them  like  fresh  wounds,  to  cause 
tension  and  irritation  to  disappear,  to  prevent  the  further 
entrance  of  germs,  and  to  allow  the  wounds  to  heal  without 
granulation. 


ELEMENTS  OF  THE  TREATMENT.  31 

If  one  will  read  over  the  principal  elements  in  the  treat- 
ment of  wounds,  he  will  at  once  comprehend  them  :  — 

Destroy  the  germs  or  living  organisms.  Then  use  anti- 
septics of  various  strengths,  according  to  the  condition  of 
the  wounds.  At  first,  it  is  prudent  to  have  the  antiseptic 
excessively  strong.     Then  make  the  atmosphere  antiseptic. 

At  the  points  where  the  germs  develop,  where  living  beings 
are  evolved,  the  strength  of  the  antiseptic  ought  to  be  in- 
creased. If  they  are  lodged  in  parts  where  there  are  sinu- 
osities, their  destruction  will  be  impossible. 

We  know  that  certain  conditions  are  particularly  favorable 
to  the  evolution  of  germs,  namely,  moisture  and  the  presence 
of  putrescible  matters,  which  are  capable  of  furnishing  pabu- 
lum for  the  fermentative  process.  These  must  be  avoided. 
Pus  and  urine  are  favorite  media  for  the  evolution  of  germs. 
We  should  take  good  care  not  to  let  them  accumulate,  and 
in  these  cases  should  use  the  most  powerful  means. 

There  are  spots  where  germs  develop  very  readily,  and 
experience  teaches  us  how  to  recognize  them.  In  general 
the  healthy  organism  is  a  less  favorable  ground  for  the  evo- 
lution of  germs  than  the  diseased. 

Excess  of  tension  is  avoided  by  whatever  insures  the  drain- 
ing-off  of  fluids. 

Direct  irritation  is  avoided  :  — 

First,  by  apposition,  which  shields  the  organic  elements 
from  all  untoward  influences,  and  in  some  way  immediately 
incorporates  them  in  the  organism. 

Second,  by  the  exclusion  of  every  foreign  body  which  is 
septic. 

Third,  by  protecting  the  wounds  from  the  direct  and  con- 
tinuous action  of  the  antiseptics. 

I  here  make  note  of  the  apparent  paradox  that  the  tempo- 
rary action  of  an  antiseptic,  even  if  it  is  caustic,  is  not  to  be 


32  ANTISEPTIC    SURGERY. 

considered  as  a  cause  of  irritation  sufficient  to  produce  suppu- 
ration. The  best  proof  of  this  is  that  the  most  powerful  car- 
bolic solutions  and  the  eight  per  cent,  solution  of  chloride  of 
zinc,  which  are  genuine  caustics,  do  not  hinder  the  rapid 
union  of  the  parts  which  they  touch. 

If  the  theory  is  correct  and  the  preceding  conditions  are 
fulfilled,  the  organic  elements  ought  to  preserve  their  maxi- 
mum of  vitality.  In  wounds  which  are  fairly  sound,  in  open 
cavities,  repair  ought  to  take  place  at  once  without  infectious 
accidents,  and  without  suppuration,  just  as  in  subcutaneous 
injuries.  In  certain  respects,  and  in  certain  particular  cases, 
repair  ought  to  be  even  more  rapid  than  in  some  subcutaneous 
lesions,  because  there  is  no  trouble  from  excess  of  tension, 
such  as  is  liable  to  occur  in  the  latter. 

Practice  justifies  the  theory,  as  the  following  pages  will 
prove.  Perhaps  the  facts  are  capable  of  some  other  theoretic 
interpretation  ;  but  no  other  could  be  as  satisfactory. 


CHAPTER    III. 

Practice  of  the  Dressing. 

The  method  of  Lister,  as  we  see,  is  not  founded  upon  a 
special  dressing ;  it  has  a  complete  theory  with  three  princi- 
pal parts,  which  point  to  as  many  prescriptions  of  the  highest 
importance.  This  method  may  be  practised  in  very  different 
ways,  all  conforming  to  these  three  indications ;  it  holds  good 
always.  It  is  also  evident  that  the  procedure  of  its  author  is 
capable  of  important  modifications.  To  achieve  his  results. 
Lister  himself  developed  his  work  by  successive  stages.  He 
has  made  applications  infinitely  more  complicated  and  less 
fortunate  than  those  which  he  commends  to-day;  and  for  ten 
years,  while  professing  the  same  beliefs,  he  has  little  by  little 
simplified  and  rendered  applicable  the  means  which  he  has 
advocated.  The  employment  of  an  antiseptic  paste  of  chalk 
applied  to  wounds,  the  use  of  costly  plasters  to  effect  occlu- 
sion, metallic  papers,  carbolized  oil,  rapidity  of  dressing  under 
compresses  of  carbolized  oil  or  water,  all  these  means  have 
successively  given  him  favorable  results  ;  but  he  only  truly 
achieved  practical  and  complete  results  after  he  began  to 
employ  the  antiseptic  gauze  and  the  carbolized  spray  in  the 
atmosphere  of  operations  and  dressings. 

Therefore,  seeing  none  but  a  historical  interest  in  recalling 
the  first  attempts,  I  will  give  only  the  procedures  which  he 
constantly  employs  in  his  service. 


34  ANTISEPTIC    SURGERY. 


I.  —  Destruction   of  germs    and   living   organisms  before    the 

operation. 

As  I  have  said  before,  the  destruction  of  germs  is  the 
principal  object  to  keep  in  view.  This  would  be  the  only 
result  sought  by  the  method  were  it  not  for  the  accessory 
conditions  which  I  have  mentioned,  and  to  which  I  shall 
return. 

Germs,  which  are  met  with  everywhere  in  the  atmosphere, 
are  found  all  over  the  surface  of  bodies  which  are  in  it;  there- 
fore, everything  which  must  come  in  contact  with  a  wound 
ought  to  be  purified  of  germs,  of  living  organisms  deposited 
upon  its  surface. 

Certain  things  especially  afford  lodgment  to  these  living 
organisms,  such  as  sponges  and  the  common  objects  on  which 
putrescible  matters  are  most  likely  to  settle. 

All  these  articles  should  be  prepared  in  such  a  manner  as 
to  make  them  perfectly  innocuous,  to  deprive  them  of  living 
beings  and  of  germs ;  and  this  result  may  be  obtained  by 
immersing  them  in  a  fermenticide  bath. 

Two  aqueous  solutions  play  an  important  part  in  the  dress- 
ing:  a  five  per  cent,  solution  of  carbolic  acid  —  the  strong 
solution  ;  and  a  two-and-a-half  per  cent.; —  the  weak  solution. 

The  instruments  are  immersed  for  some  time  before  the 
operation  in  the  strong  solution.  It  is  well  to  rub  their  sur- 
face with  a  linen  cloth  or  a  sponge  in  order  to  moisten  them 
in  their  entire  extent  and  in  all  their  crevices. 

The  sponges  are  permanently  kept  in  this  strong  solution. 
Before  using  them  in  the  operation,  they  should  be  carefully 
wrung  out. 

Every  object,  before  it  is  allowed  to  touch  the  wound  or 
its  surroundings,  should  be  purified  in  the  same  manner. 


DESTRUCTION   OF  GERMS.  35 

The  field  of  operation,  that  is,  the  site  of  the  operation,  and 
the  neighboring  parts,  should  be  carefully  cleansed  with  a 
sponge  saturated  with  the  strong  solution. 

Many  precautions  have  been  recommended  for  this  prepar- 
ation of  the  field  of  operation,  which  do  not  seem  to  be  indis- 
pensable. 

It  has  been  recommended  to  soap  the  region  with  the 
greatest  care,  and  to  wash  it  with  ether  to  remove  absolutely 
all  oily  matter.  It  would  be  bad  taste  to  deprecate  this 
excess  of  neatness ;  but  since  it  has  been  objected  to  the 
method  that  it  is  too  intricate,  it  is  no  more  than  fair  to 
exclude  useless  complications. 

Now,  Lister  observed  that  the  watery  solution  of  carbolic 
acid  is  penetrating.  It  easily  soaks  into  the  layers  of  the 
epidermis,  and  we  may  be  sure  that,  when  the  bathing  with 
the  strong  solution  has  been  done  with  sufficient  care,  the 
region  is  perfectly  cleared  of  germs.  This  is  the  practice 
which  I  have  seen  followed  in  the  Edinburgh  Infirmary  and 
in  London  by  the  professor,  and  the  excellent  results  of 
which  I  have  noted.  In  my  turn  I  have  followed  it,  and 
have  nothing  but  praise-  for  it.  If  the  region  is  very  dirty  or 
greasy,  one  may,  as  a  preliminary,  wash  it  with  hot  water, 
which  prepares  it  very  well  for  the  action  of  the  carbolized 
solution. 

The  action  of  the  strong  carbolized  water  is  sufficient  for 
the  instruments ;  the  precaution  of  rubbing  them  is  useful, 
because  the  water  often  runs  off  of  their  surfaces  and  their 
angles  sometimes  contain  putrid  matter.  In  the  case  of 
certain  instruments  which  have  irregular  extremities,  such  as 
forceps.  Lister  thinks  it  well  to  dip  them  in  carbolic  oil,  con- 
taining a  tenth  part  of  the  acid. 

The  hands  of  the  operator  and  of  his  assistants,  which  will 
come  in  contact  with  the  wound  and  the  instruments,  should 


36  ANTISEPTIC    SUKGEEY. 

be  purified  in  their  turn,  and  every  time  that  they  are  re- 
moved for  any  cause  whatever  from  the  carbolized  atmos- 
phere in  which  the  operation  is  being  performed,  they  should 
be  purified  anew.  For  this  purpose  the  strong,  really  caustic, 
solution  is  not  necessary.  It  is  sufiicient  to  dip  the  hands 
into  the  weak  solution. 

Such  are  the  preparations,  the  necessary  preliminaries  of 
an  antiseptic  operation,  and  one  can  see  that  it  practically 
amounts  to  little  but  attention  to  the  minute  details  of  clean- 
liness. And,  for  my  part,  long  before  I  adopted  the  applica- 
tion of  the  antiseptic  method,  I  pursued  this  course  as  often 
as  possible,  and  never  had  occasion  to  regret  it.  The  chiefs 
of  the  service  and  the  students  in  our  hospitals  have  often 
been  charged  with  lack  of  neatness,  for  which  they  should 
not  be  blamed,  in  the  actual  condition  of  affairs.  It  is  diffi- 
cult, in  the  present  circumstances,  for  a  chief  of  the  service  to 
wash  his  hands,  but  it  is  almost  impossible  for  students.  As 
it  is  in  human  nature  to  struggle  as  little  as  possible  with 
difficulties,  the  result  is  bad.  The  employment  of  the  anti- 
septic method  changes  all  this,  for  even  the  nurses  now  have 
clean  hands  without  trouble. 

What  is  said  here  of  persons  is  equally  applicable  to  the 
instruments,  and  I  have  come  to  be  quite  particular  about 
their  cleanliness  as  regards  putrescible  matters.  We  are 
insured  against  all  danger  when  they  are  antiseptically  neat. 
Even  the  most  putrid  sponges  are  purified  with  great  facility, 
as  one  can  easily  observe. 

II.  —  Destruction  of  germs  during  the  operation. 

Thus,  all  the  precautions  are  taken,  everything  which  is  to 
touch  the  wound  is  aseptic,  deprived  of  the  elements  of  sep- 
ticity.     But  in  the  course  of  the  operation  the  atmosphere 


THE   SPRAY.  37 

will  pour  upon  the  wound,  upon  the  operator,  upon  the  in- 
struments, torrents  of  germs  which  could  not  be  neutralized 
at  the  time.  To  prevent  this.  Lister  at  first  sought  to  the 
best  of  his  abilit}''  to  protect  the  wound  from  the  access  of 
fresh  air,  operating  behind  a  compress  soaked  in  carbolized 
oil,  and  covering  the  wound  as  rapidly  as  possible.  All  this, 
however,  seemed  to  him  insufficient ;  and  at  last  he  conceived 
the  happy  idea  of  creating  around  the  wound  an  antiseptic 
atmosphere.  The  pulverization  of  the  carbolized  water  in  a 
powerful  stream  on  the  field  of  operation  brought  him  abun- 
dant success. 

This  manoeuvre,  to  which  unjustifiable  theoretic  objections 
have  been  made,  is  extremely  simple  ;  with  any  one  of  the 
pieces  of  apparatus  which  we  shall  study  further  on  it  can  be 
made  without  trouble.  It  merely  consists  in  enveloping 
the  region  of  operation,  the  hands  of  tlie  surgeon  and  of  his 
assistants,  in  the  spray  furnished  by  a  reservoir  of  carbolized 
water,  thus  creating  a  pure  artificial  atmosphere  around  the 
wound. 

This  spray  ought  to  be  so  fine  as  not  to  interfere  with  or 
wet  the  operator,  and  still  be  abundant. 

The  apparatus  requires  a  certain  amount  of  attention. 
The  assistant  should  be  familiar  with  his  work.  He  should 
not  keep  too  near  the  wound,  —  a  mistake  which  I  have 
seen  made.  The  liquid  stream  is  not  intended  to  have 
a  local  action  on  the  wound.  It  should  be  so  far  removed 
that  the  field  of  operation  may  be  enveloped  in  a  cloud. 
Care  should  be  taken  to  keep  it  aimed  at  the  wound,  not  to 
send  it  into  the  face  of  the  operator,  and  to  accommodate  it 
always  to  his  changes  of  position,  that  an  antiseptic  atmos- 
phere may  constantly  be  preserved.  It  is  well  to  look  out 
for  the  stream ;  it  is  even  necessary,  in  this  respect,  to  mis- 
trust the  steam  apparatus,  for  it  is  not  uncommon  to  see  the 


38  ANTISEPTIC    SURGERY. 

steam  rush  out  without  drawing  up  the  antiseptic  fluid,  and 
thus  the  antiseptic  action  is  lost.  Drafts  of  air  should  be 
taken  into  account,  as  they  displace  the  pulverized  stream 
and  may  make  it  inoperative.  These  minuti^  are  somewhat 
difficult  to  observe,  but  are  indispensable  to  the  accomplish- 
ment of  the  antiseptic  protection.  Some  surgeons  have  over- 
looked the  causes  of  their  lack  of  success,  and  have  blamed 
the  method,  when  really  the  fault  was  their  own,  in  having 
failed  to  observe  these  precautions. 

If,  from  any  cause,  the  spray  fails,  or  if  one  wishes  to  give 
his  assistant  a  rest  during  a  dressing,  it  is  easy  to  take  a  com- 
press, soak  it  in  a  weak  solution,  and  with  it  cover  for  a 
little  while  the  operating  field  and  the  neighboring  parts. 

There  is  one  direction  which  it  is  worth  while  to  remember: 
irritation  of  the  eyes  of  the  patient  by  the  spray  should  be 
avoided  ;  so,  during  the  operation  and  the  dressings,  one 
should  habitually  cover  the  face  with  a  napkin  or  a  dry 
compress. 

No  other  special  precautions  during  an  operation  need  be 
mentioned.  The  sponges  are  wrung  out  in  the  weak  solu- 
tion, but  when  the  operation  is  over,  the  strong  solution 
should  be  used  for  the  bathing.  This  bathing  gives  the  blood 
and  muscles  a. gray  or  chocolate  color,  which  is  clear  and 
characteristic.     It  is  a  capital  precaution  to  take. 

III. — Defence  against  germs  after  the  operation. 

When  this  is  over,  it  is  still  necessary  to  maintain  about 
the  wound  an  antiseptic  atmosphere,  and  this  is  the  object  of 
the  antiseptic  gauze,  an  essential  element  of  the  dressing. 

The  wound  should  remain  in  a  sort  of  sheath  made  by  this 
gauze,  which  is  of  the  consistency  of  common  tarlatan.  It 
is  saturated  with  resin  and  paraffin,  mixed  with  carbolic  acid ; 


THE   GAUZE.  6\i 

it  gives  up  the  carbolic  acid,  which  is  volatilized  little  by  little, 
particularly  in  contact  with  warm  bodies.  By  covering  this 
gauze  with  an  impervious  cloth,  the  carbolized  atmosphere  is 
confined  about  the  wound.  Moreover,  one  is  sure  that  the 
discharge  from  the  wound  will  traverse  the  entire  dressing 
before  reaching  fresh  air.  If  it  were  otherwise,  it  would  run 
directly  through  the  gauze  to  the  air.  There  it  would  be- 
come infected  by  the  entrance  of  germs,  and,  if  the  passage 
was  short,  the  infection  would  be  propagated  across  the  dress- 
ing, although  it  was  antiseptic. 

From  this  arrangement  a  curious  and  easily  observed  phe- 
nomenon results.  When  one  removes  the  dressings  within  a 
day  or  two,  there  is  usually  a  good  deal  of  discharge.  If  it 
happens,  for  example,  to  be  in  a  member  which  rests  on  a 
cushion,  this,  being  saturated  with  fluids,  may  emit  a  bad  odor. 
We  remove  the  dressing  whence  all  this  discharge  has  come : 
it  contains  more  or  less  fluid ;  its  folds  are  stained  and  satu- 
rated, but  no  odor  comes  from  it. 

We  renew  the  dressing  with  the  precaution  of  the  spray, 
washing  the  wound  with  the  strong  solution  first,  afterwards 
with  the  weak,  according  to  our  apprehension  of  too  great 
irritation  of  the  wound.  We  are  guided  in  renewing  the 
dressing  by  the  amount  of  discharge :  at  first,  every  day,  if  it 
is  necessary ;  then  every  other  day,  and  afterwards  less 
frequently. 

In  this  manner  the  conditions  relating  to  germs  are  ful- 
filled. Though  I  have  mentioned  a  good  many  minutias,  I 
insist  that  practically  it  is  only  necessary  to  establish  the 
habit ;  and  I  can  assert  that,  from  the  beginning  of  the  trial 
during  my  term  of  service  at  the  hospital,  my  pupils,  as  well 
as  myself,  took  all  the  antiseptic  precautions,  and  that  our 
dressings,  in  truth  quite  infrequent,  occupied  no  more  time 
than  was  consumed  by  other  methods,  always  excepting  the 
wadded  dressing  of  Guerin. 


40  ANTISEPTIC    SUKGEEY. 

Drainage  of  fluids  ;  precaution  against  excess  of  tension. 

As  I  have  said  above,  the  dressing  ought  to'fulfil  other  in- 
dications. The  first,  and  without  doubt  the  most  important, 
is  that  of  drainage.  The  fluids  ought  always  and  from  every 
point  to  have  free  vent.  Lister  always  insures  this  condition, 
selecting  his  methods,  and  giving  preference  to  those  which 
make  drainage  easy.  Then  he  immediately  closes  the  wound, 
but  leaves  several  small  openings,  in  which  he  places  drain- 
age-tubes. It  may  be  said  that  Lister  never  uses  a  dressing 
without  employing  the  tubes  of  Chassaignac,  as  he  has  the 
courtesy  to  call  them,  in  honor  of  our  eminent  countryman  ; 
but  he  uses  them  in  a  little  different  manner  from  that  which 
is  customary  with  us.  He  does  not  pass  a  loop  from  one 
point  of  the  wound  to  another,  but  introduces  a  tube  into  the 
opening  perpendicularly,  —  long  enough  to  terminate  just  at 
the  surface.  At  the  outer  extremity  are  fastened  two  threads 
designed  to  keep  it  in  place  and  to  draw  it  out  by  at  each 
dressing. 

The  tube  should  not  be  too  long  ;  it  should  make  a  canal 
for  easy  drainage,  but  it  ought  not  to  strike  against  the  soft 
parts  to  irritate  them.  To  introduce  it  perpendicularly  into 
the  passages,  which  are  often  very  long,  Lister  uses  an  instru- 
ment Avhich  he  calls  fistula-forceps.  This  is  simply  a  dressing 
forceps,  with  very  long  and  slender  blades.  If  the  tube  is 
too  long,  he  withdraws,  shortens,  and  then  replaces  it.  If 
it  projects  beyond  the  surface,  it  will  be  pressed  upon  by 
the  dressing,  and  will  irritate  the  deep  parts,  and  this  must 
be  avoided. 

At  each  dressing  the  drainage-tubes  are  withdrawn  and 
washed  in  a  strong  solution,  to  clear  them  of  the  blood  and 
puriform  matter  which  they  may  contain.  Each  time  it  is 
necessary  to  diminish  their  length,  for  the  wound  heals  rapidl}'' 


DRAINAGE.  41 

at  the  bottom,  and  seems  to  drive  them  out.  After  being 
shortened  they  are  put  back  again.  Tubes  of  smaller  calibre 
should  be  substituted  for  these,  if  they  are  large,  and  gradu- 
ally a  diminution  in  size  should  take  place. 

When  we  see  that  the  discharge  has  entirely  ceased,  the 
tube  is  withdrawn  and  the  external  wound  closes  up.  It  is 
always  necessarj^  to  guard  against  too  speedy  withdrawal, 
for  the  fluids  accumulate  very  rapidly  and  make  abscesses. 

The  employment  of  sufficiently  large  tubes  is  imperatively 
insisted  on.  Their  walls  should  be  very  thick,  else  they  col- 
lapse, and  their  capacity  for  drainage  ceases. 

It  is  well  to  place  them  beforehand  in  a  vessel  of  strong 
carbolized  water ;  the  caoutchouc  absorbs  the  carbolic  acid 
well,  and  remains  absolutely  aseptic,  is  even  somewhat 
antiseptic. 

There  are  other  precautions  necessary  to  insure  drainage. 
Care  must  be  taken  with  regard  to  the  position  of  members, 
not  to  raise  the  stumps  as  much  as  is  generally  done.  At 
each  dressing  we  must  make  sure  that  the  drainage  works 
well,  by  pressing  upon  the  lips  of  the  wound.  If  the  exist- 
ence of  culs-de-sac  is  suspected,  gentle  pressure  should  be 
made  with  a  sponge.  If  points  of  suture  seem  too  tight,  they 
should  be  cut ;  if  even  at  one  of  them  there  are  manifest 
traces  of  inflammation,  we  must  not  hesitate  to  plunge  in  the 
point  of  a  bistouri,  give  exit  to  the  accumulated  drops  of  pus, 
and  put  in  a  small  drainage-tube.  I  have  done  it  with 
success. 

Perhaps  there  may  be  a  considerable  failure  of  drainage,  in 
which  case,  besides  local  tension,  one  observes  a  general  feb- 
rile state.  Removal  of  the  constriction  is  necessary,  and 
must  be  ample,  even  if  one  has  to  take  some  stitches  after- 
wards to  close  the  wound.  Sometimes  the  drainage  opening 
is  large  enough,  and  then  one  can  profitably  inject  a  little 

4 


42  ANTISEPTIC    SURGERY. 

of  the  strong  or  the  weak  solution,  according  to  the  case,  to 
wash  out  all  putrescible  matter.  But  this  should  be  entirely 
exceptional.  I  once  knew  Lister,  after  having  opened  a  knee 
for  an  old  dropsy,  to  find  fever  the  third  day,  and  attribute 
it  to  the  fact  that  the  chance  for  drainage  was  not  sufficient. 
He  made  a  larger  opening,  and  the  fever  abated. 

Precaution  against  irritation. 

Lister  seeks  for  the  most  rapid  union  possible,  so  he  always 
immediately  sews  up  the  lips  of  wounds.  This  suture  is 
generally  made  with  silver  wire,  and  resembles  all  interrupted 
sutures  ;  but  in  addition  he  usually  takes  a  deep  suture  of 
large  silver  wire,  each  extremity  of  which  pierces  and  is  then 
twisted  around  a  plate  of  lead.^  When  this  is  tightened,  it 
bears  all  the  strain  ;  tension  and  swelling  do  not  show  them- 
selves even  upon  the  lips  of  the  wound,  in  which  union  is 
obtained  more  rapidly  and  firmly  than  without  the  deep 
stitch. 

Lister  cuts  the  wires  very  early  in  order  to  avoid  tension 
of  the  parts  which  they  hold ;  but,  in  order  that  these  may 
not  be  altogether  deprived  of  support,  he  often  leaves  the 
wires  in  place. 

There  is  one  rule  which  it  is  useful  to  know  :  one  need  not 
be  anxious  about  the  blood  which  is  poured  out  between  the 
flaps.  It  is  necessary  to  take  great  care  not  to  evert  a  flap 
or  displace  a  stitch  for  the  purpose  of  removing  a  clot  of 
blood ;   for  it  will  not  hinder  the  phenomena  of  repair  or 

1  The  lead  plates  have  applications  outside  the  antiseptic  method. 
Lister  especially  recommends  them  in  the  operation  for  hare-lip,  and  I 
have  employed  in  this  case  four  plates  to  hold  the  deep  sutures.  I  can- 
not too  highly  recommend  this  procedure,  -which  always  requires  close  at- 
tention. I  have  employed  with  it  on  the  outside,  an  ointment  of  boracic 
acid,  the  formula  for  which  -will  be  found  on  a  subsequent  page.     J.  C. 


APPLICATION    OF   THE   DRESSING.  43 

provoke  suppuration,  as  customarily  happens  in  ordinary 
dressings. 

In  conformity  to  the  principles  which  we  have  established, 
the  line  of  union  and  the  free  angles  of  the  wound  ought 
not  to  be  reached  by  initating  substances,  under  penalty 
of  the  formation  of  granulations  and  of  suppuration.  One 
may,  and  doubtless  should,  wash  them  at  the  dressing  with 
even  strong  solutions  ;  but  it  is  undesirable  to  have  irri- 
tants remain  in  contact  with  the  denuded  parts.  Now,  the 
dressing  constantly  disengages  carbolic  acid,  and,  to  prevent 
its  action  upon  the  denuded  parts,  we  employ  the  protective. 
It  has  been  quite  difficult  to  accomplish  the  manufacture  of 
this,  which  is  made  of  very  thin  taffeta  silk,  gummed,  covered 
with  copal  varnish  and  dextrine,  and  thus  rendered  absolute- 
ly impervious  to  carbolic  acid.  This  material,  which  is  green 
and  very  pliable,  is  placed  accurately  over  the  wound  ;  we 
cut  a  narrow  strip  of  it,  which  overlaps  the  wound  a  very 
little,  and  over  this  apply  the  antiseptic  gauze. 

We  come  now  to  the  application  of  the  dressing,  and  the 
arrangement  of  its  constituent  parts. 

The  Dressing. 

The  piece  of  protective  is  wet  in  the  weak  carbolized  water 
to  divest  it  of  all  germs,  for  in  itself  it  has  no  antiseptic  qual- 
ity. It  is  placed  upon  the  wound,  which  it  should  overlap 
but  slightly,  in  order  that  the  discharge  may  come  as  soon  as 
possible  to  the  gauze,  the  antiseptic  substance. 

Then  we  take  some  pieces  of  the  antiseptic  gauze,  and, 
having  soaked  them  in  the  weak  solution,  wring  them  out 
and  place  them  directly  upon  the  protective.  This  precau- 
tion is  necessary  in  order  that  the  gauze  may  surely  be  anti- 
septic,  because   it  gives  up  the    carbolic  acid  but  slowly. 


44  ANTISEPTIC    SURGERY. 

and,  during  its  exposure  to  the  air,  germs  may  be  deposited 
which  it  is  essential  to  destroy  immediately  with  carbolized 
water. 

For  the  same  reason,  we  wet  slightly  with  the  same  weak 
solution  the  surface  of  the  dressing  which  is  applied  to  the 
skin. 

The  last  and  principal  piece  of  the  dressing  is  ordinarily 
composed  of  eight  folds  of  gauze,  one  upon  another.  If  cir- 
cumstances require,  it  is  made  thicker. 

Between  the  seventh  and  eighth  folds  is  placed  the  imper- 
vious cloth  or  mackintosh,  with  the  smooth  surface  turned 
towards  the  wound.  The  dressing  ought  to  extend  a  con- 
siderable distance  beyond  the  wound,  and,  if  it  is  applied  to 
a  limb,  it  should  reach  entirely  around  it. 

The  dressing  ought  to  be  crossed  as  much  as  possible,  in 
such  a  way  that  the  fluids  in  draining  can  find  no  gap  and 
will  be  obliged  to  run  over  the  greatest  possible  extent  of 
the  dressing. 

The  mackintosh  should  be  placed  between  the  last  layers 
of  the  dressing,  because  otherwise  it  does  not  lie  close  enough, 
and  may  allow  spaces  to  form  under  which  air  may  pass, 
and  thus  there  be  developed  phenomena  of  infection,  which 
can  be  avoided  by  this  precaution. 

The  dressing  should  be  kept  in  place  by  bandages  made  of 
antiseptic  gauze.  This  kind  of  bandage  is  extremely  con- 
venient, does  not  slip,  and  is  very  firm  and  strong.  Its 
strength  is  such  that  in  certain  resections,  particularly  those 
of  the  elbow,  we  can  dispense  with  splints,  if  we  apply  these 
bandages  properly ;  they  are  fastened  with  pins,  or  by  tying 
two  free  ends. 

By  the  assistance  of  these  gauze  bandages,  the  dressing 
ought  to  be  so  well  fixed  in  place  that  it  will  not  slip.  To 
this  end  the  bandage  is  moderately  tightened. 


■MODIFICATIONS.  45 

The  better  to  hold  it  firmly  upon  the  limbs,  Lister  usually 
places  outside  the  dressing  at  its  extremities  two  rubber  straps, 
which  by  their  elasticity  keep  the  dressing  so  tight  that  no 
leakage  or  current  of  air  can  carry  germs  under  the  cuirass 
thus  formed.^ 

These  are  the  principal  points  in  the  practice  of  the  dress- 
ing. But  this  is  subject  to  a  number  of  conditions  accord- 
ing to  the  circumstances  of  the  case.  If  the  dressing  cannot 
be  made  broad  enough,  it  should  be  thicker.  We  use  the 
gauze  to  fill  up  the  hollows  by  which  air  may  rush  in,  —  the 
axilla,  in  amputations  of  the  breast;  the  ear,  in  injuries  of 
the  parotid  region,  etc. ;  and  the  simple  or  antiseptic  wadding 
around  the  edge,  in  all  cases  where  it  is  needed  to  complete 
the  closure  of  a  dressing  which  has  a  tendency  to  curl  up  at 
the  border. 

For  certain  dressings  Lister  still  employs  a  lint  saturated 
with  boracic  acid,  well  prepared  in  Edinburgh,  and  very  con- 
venient, particularly  when  the  correct  application  of  the 
dressing  just  described  is  impossible. 

But  for  all  these  details,  the  experience  and  ingenuity  of 
the  surgeon  must  come  into  play ;  and  when  he  knows  the 
principles,  he  should  seek  for  everything  which  will  assist  him 
in  their  application. 

Among  the  accessory  means  I  will  give  a  description  of  the 
compression  with  sponge  which  Lister  recommends. 

When,  in  the  course  of  an  operation,  he  has  made  a  very 
large  wound,  after  closing  it,  he  thinks  it  well  to  exercise 
some    compression    upon    the    sac    thus    formed ;    and    for 

1  The  application  of  the  rubber  straps  here  mentioned  is  limited 
practically  to  dressings  on  the  limbs.  When  the  wound  is  on  the  trunk, 
a  long,  elastic  bandage  may  be  used  to  confine  the  upper  and  lower  bor- 
ders of  the  dressing  in  the  most  desirable  position,  and  yet  not  be  so 
tight  as  to  interfere  with  the  necessary  movements  of  the  thorax  and 
abdomen.  The  ordinary  suspender-webbing  answers  admirably  for  this 
purpose. 


46  AI^TISEPTIC    SURGERY. 

the  first  dressing,  he  applies  over  a  piece  of  protective  a 
sponge  of  convenient  form,  soaked  in  strong  carbolized  water 
and  well  wrung  out  ;  over  this  he  puts  the  gauze  dressing 
and  the  bandages  according  to  custom.  The  sponge  makes 
effectual  compression,  and  besides  absorbs  and  neutralizes  the 
fluids  which  are  discharged  in  abundance.  In  the  subsequent 
dressings,  this  practice  is  usually  unnecessary.  We  should 
always  be  careful  to  place  a  layer  of  protective  between  the 
sponge  and  the  skin,  for  without  this  a  kind  of  blister  would 
be  formed,  and  the  patient  would  suffer  intensely  from  burn- 
ing. This  is  one  way  of  practising  compression  upon  wound 
cavities. 

All  the  ligatures  have  been  enclosed  in  the  wound,  as  I 
shall  explain  presently,  and  the  dressing  is  adjusted.  What 
remains  to  be  done  for  the  patient  ? 

We  should  advise  such  a  position  of  the  wounded  part  as 
will  favor  easiest  drainage.  Generally  the  dressing  is  re- 
newed at  the  end  of  twenty-four  hours,  less  frequently  at  the 
end  of  forty-eight. 

Although  the  extent  of  the  wound  may  be  small,  there  will 
be  a  considerable  discharge  of  serum.  This  immediate  dis- 
charge, abundant  after  all  large  operations,  is  perhaps  greater 
after  those  which  are  performed  by  this  method,  probably  by 
virtue  of  a  special  action  of  carbolic  acid  upon  the  tissues. 

In  uncovering  the  wound  one  should  take  the  same  pre- 
cautions as  before  with  respect  to  the  atmosphere,  the  hands, 
and  the  instruments.  Then  he  will  notice  if  the  parts  are 
stretched,  and  if  they  are  not,  the  tubes  are  left  in  place  for 
this  first  dressing ;  but,  if  they  are  stretched,  it  is  necessary 
to  withdraw  the  tubes  to  empty  them  of  clots  ;  and  if  fluids 
have  accumulated,  they  are  forced  out  by  gentle  pressure. 

The  wound  or  stump  is  washed  lightly  with  the  strong 
solution,    unless  it  is  irritated,    even  to  a  slight   extent,    in 


INDICATIONS   FOE,   RENEWAL.  47 

which  case  the  weak  solution  should  be  used.  The  tubes 
are  then  cautiously  replaced.  The  sutures  are  carefully  ex- 
amined, that  they  may  be  loosened  if  it  is  necessary.  Then, 
as  at  the  original  dressing,  we  apply  — 

First,  the  protective,  after  having  dipped  it  in  the  weak 
solution  ; 

Second,  some  pieces  of  gauze  moistened  in  weak  solu- 
tion ; 

Third,  the  dressing,  —  eight  layers  of  gauze,  with  the  im- 
permeable cloth  between  the  last  two  layers ; 

Fourth,  the  gauze  bandage. 

This  dressing  ought  to  extend  a  good  deal  beyond  the 
region  of  operation. 

It  is  not  an  infrequent  dressing  ;  it  is  applied  often  at  first, 
less  frequently  afterwards.  The  especial  guide  for  its  re- 
moval is  the  amount  of  discharge.  The  existence  of  pain 
would  also  indicate  its  removal.^ 

Whenever  the  discharge  appears  at  the  edge  of  the  dress- 
ing and  stains  it,  prudence  requires  us  to  remove  it  in  order 
to  avoid  all  chance  of  the  propagation  of  putrefaction. 

If  any  odor  is  detected,  the  dressing  should  be  absolutely 
distrusted,  for  it  should  have  no  odor  at  all. 

The  perusal  of  this  work  will  show  that  there  are  many 
modifications  to  be  introduced  according  to  the  case  ;  how- 
ever, to  give  a  very  striking  example  of  what  may  be  done, 
I  may  be  allowed  to  quote  the  report  of  one  of  my  oldest 

1  After  almost  any  operation  there  is  likely  to  be  some  pain,  even  if 
the  wound  has  been  subjected  to  the  ansesthetic  influence  of  the  carbolic 
spray  ;  but  there  is  no  occasion  to  renew  the  dressing  on  this  account, 
unless  the  suffering  is  considerable  and  persistent. 

Another  circumstance  which  imperatively  demands  the  removal  of  the 
dressing  and  the  careful  inspection  of  the  wound  is  that  harbinger  and 
attendant  of  septicaemia,  —  the  rapid  rise  of  the  temperature,  and  its  con- 
tinuance at  a  point  much  above  37.7°  C. 


48  ANTISEPTIC    SUEGEET. 

cases,  published  in  the  Journal  of  Practical  Medicine  and 
Surgery,  for  February,  1876.  This  will  necessitate  some 
repetition,  but  it  seems  to  me  typical  enough  to  aid  those  who 
wish  to  apply  the  method.  I  give  it  as  an  ordinary  case,  in 
which  I  think  it  would  have  been  possible  even  to  abridge 
the  treatment  some  days. 

A  man,  aged  forty-two,  entered  the  hospital  during  my 
service  for  treatment  of  a  vicious  cicatrix  of  the  left  leg.  He 
had  been  burned  two  years  before  by  melted  zinc,  and  the 
skin  of  the  whole  leg  was  so  completely  destroyed  that  one 
could  see  nothing  but  a  vast,  persistent  ulcer,  suppurating 
and  bleeding.  This  had  also  produced  a  permanent  flexion 
of  the  leg  upon  the  thigh,  which  had  not  yielded  to  several 
attempts  at  extension  and  division  of  the  ham-string  tendons 
in  other  hospitals.  Sinuses,  discharging  pus  profusely,  kept 
breaking  out  on  the  internal  aspect  of  the  thigh,  and  he 
urgently  entreated  to  be  relieved  of  this  useless  and  danger- 
ous member. 

It  was  easy  to  see  at  the  first  examination  that  the  limb 
could  never  be  entirely  restored.  Still  I  did  not  want  to 
accede  to  his  desire  for  an  amputation  of  the  thigh ;  it  seemed 
to  me  that  the  sinus  might  be  healed,  then  the  leg  removed 
at  the  upper  third,  and  that  he  might  walk  well  upon  the 
flexed  knee. 

I  first  treated  the  sinus  of  the  thigh  ;  the  inflammatory 
phenomena  abated  as  the  abscess  disappeared,  and  I  resolved 
to  proceed  to  amputate  at  once. 

On  the  tenth  of  November,  1875,  I  amputated  the  leg  at 
the  upper  part  by  the  circular  method. 

I  had  great  difliculty  in  finding  enough  skin  to  make  even 
a  scant  covering.  By  sawing  the  bone  at  the  highest  possible 
point,  I  was  just  able  to  close  the  wound. 

I  applied   five  catgut  ligatures   to  the  vessels,  and  then 


AN  INSTRUCTIVE   CASE.  49 

sewed  up  the  entire  wound,  excepting  the  two  extremities. 
I  took  also  a  deep  suture  with  lead  plates  at  each  end  of  the 
wire,  to  assist  apposition. 

At  each  side  of  the  stump  was  inserted  a  straight  drainage- 
tube,  fastened  with  a  thread  to  keep  it  in  place.  The  dress- 
ing was  placed  over  all. 

The  operation  was  performed  with  all  the  precautions 
suggested  by  Professor  Lister,  which  are  thus  summed  up : 

I  washed  the  operating  field  with  a  strong  carbolic  solution 
(one  part  of  glacial  acid  to  twenty  of  water). 

The  instruments  and  sponges  were  placed  in  the  same 
solution. 

The  hands  of  the  operator  and  assistants  were  washed  in 
the  weak  solution  (one  part  to  forty  of  water). 

A  spray  of  the  same  solution  was  thrown  upon  the  field  of 
operation  from  first  to  last. 

Catgut  ligatures  were  used  and  cut  short  in  the  wound. 

An  occurrence  worthy  of  consideration  marked  the  end  of 
the  operation.  I  did  not  employ  the  system  of  Esmarch  to 
prevent  bleeding,  but,  as  I  am  accustomed  to  do,  made  com- 
pression at  the  upper  part  of  the  limb  with  an  india-rubber 
band.  In  similar  cases  it  often  happens  that  there  is  indefi- 
nitely prolonged  oozing  of  blood  from  the  entire  surface  of 
the  wound.  Following  in  this  the  practice  of  Professor 
Lister,  I  proceeded  with  moderate  speed,  and  inserted  the 
sutures. 

Over  all  was  placed  the  dressing :  first  the  protective, 
then  the  antiseptic  gauze,  last  the  mackintosh  or  impervious 
material. 

I  renewed  the  dressing  the  next  day.  There  was  no 
change  ;  still  there  had  been  considerable  discharge  into  the 
dressing,  which  was  odorless.  The  stump  being  distended 
by  the  effused  blood,  I  loosened  the  deep  suture  ;  I  removed 


50  ANTISEPTIC    SURGERY. 

the  drainage-tubes  to  cleanse  them,  taking  good  care  to  evac- 
uate the  effused  blood,  and,  the  stump  having  been  washed 
with  the  strong  solution,  the  dressing  was  replaced  for  forty- 
eight  hours. 

On  the  thirteenth  of  November,  I  removed  the  dressing. 
This  time  there  was  little  discharge  ;  there  was  a  small 
amount  of  brown  liquid  in  the  tubes,  which  I  withdrew  to 
wash  and  shorten.  The  stump,  which  was  smaller  and  not 
changed  in  color,  was  bathed  in  the  strong  solution,  and  the 
dressing  was  renewed. 

On  the  sixteenth  of  November,  I  again  renewed  the  dress- 
ing ;  I  took  out  the  stitches,  the  union  was  perfect ;  I  removed 
the  tubes  and  shortened  them  considerably.  I  found  in  the 
dressing  and  in  the  tubes  a  few  drops  of  a  puriform  liquid, 
which  was  without  odor.  I  repeated  the  bath  with  the  strong 
solution. 

As  all  the  conditions  had  been  perfectly  complied  with,  I 
was  annoyed  by  the  presence  of  these  drops,  which,  though 
not  pus,  were  at  least  puriform,  and  I  reflected  on  their 
possible  origin.  I  thought  that  it  might  be  attributed  to 
excessive  irritation  of  both  extremities  of  the  wound,  and  I 
resolved  not  to  use  the  strong  carbolic  solution  in  renewing 
the  dressing. 

At  the  fourth  dressing,  on  the  twentieth  of  November, 
the  appearances  were  the  same ;  the  liquid  in  the  tubes  was 
similar.  I  shortened  the  tubes  very  much,  and  contented 
myself  with  washing  with  carbolic  water  of  one  part  to 
forty. 

At  the  fifth  dressing,  on  the  twenty-fourth  of  November,  I 
only  found  some  drops  of  cloudy  fluid,  the  dressing  being 
hardly  stained. 

At  the  sixth  dressing,  on  the  twenty-ninth  of  November,  I 
withdrew  the  drainage-tubes,  which  had  been  shortened  to 


EAPID    RECOVERY.  51 

their  minimum  the  preceding  time,  and  washed  with  the  weak 
solution. 

Five  days  after,  the  fourth  of  December,  when  I  took  off 
the  dressing,  it  was  not  moist,  everything  was  healed,  and  I 
redressed  the  wound  only  because  I  had  the  materials  pre- 
pared. 

On  no  day  did  the  patient  have  real  fever.  The  tempera- 
ture on  the  first  nine  days  was  as  follows  :  first  day,  evening 
38.2°  C. ;  second  day,  morning  38°,  evening  38.3°;  third, 
morning  37.4°,  evening  37.8°  ;  fourth,  morning  37°,  evening 
38.4°  ;  fifth,  morning  37.2°,  evening  38.4° ;  sixth,  morning 
37.2°,  evening  37.6 ;  seventh,  morning  37.2°,  evening  37.4°  ; 
eighth,  morning  36.8°,  evening  37° ;  ninth,  morning  36.6°. 
After  this  the  morning  temperature  generally  ranged  from 
36.4°  to  36.8°,  and  that  of  the  evening  never  exceeded 
37.4°. 

Here  was  a  man  entirely  cured  in  twenty-four  days  ;  and 
still  there  was  nothing  extraordinary  in  the  case,  for  the 
phases  of  repair  were  exactly  those  indicated  by  Professor 
Lister.  The  wound,  maintained  in  apposition,  gradually 
closed  at  the  two  extremities  ;  there  was  an  ordinary  amount 
of  discharge.  The  catgut  ligatures  remained  in  the  stump 
without  creating  any  irritation. 

The  blood  which  was  effused  into  the  stump  behind  the 
sutures,  and  the  presence  of  which  I  can  prove  by  my 
internes,  and  by  the  students  who  followed  my  service,  did 
not  putrefy  and  did  not  interfere  with  the  process  of  repair, 
as  it  always  does  in  other  methods  of  dressing,  as  all  the 
advocates  of  union  by  first  intention  acknowledge. 

There  was  a  curious  incident,  which  seems  to  decidedly 
support  the  Lister  theory.  Having  seen  that  a  puriform 
liquid  was  formed,  I  supposed  that  it  was  caused  by  excessive 
irritation  of  the  wound  from  a  strong  solution  ;  I  employed  a 


52  ANTISEPTIC    SURGERY. 

weak  solution,  and,  after  the  next  dressing,  there  was  no 
more  discharge. 

There  was  no  suffering.  His  temperature  being  but  slightly 
elevated,  the  patient  had  only  a  mild  traumatic  fever,  and 
this  conforms  well  to  the  theory. 

So  much  for  the  phj^siological  process.  Now  look  at  the 
result  as  it  concerned  the  patient.  In  twenty-four  days  a 
man  in  a  deplorable  state  of  health  recovered  entirely  from  an 
amputation  of  the  leg  at  the  upper  third.  The  sinus  of  the 
thigh,  which  was  discharging  pus,  cicatrized  spontaneously. 
There  was  no  suffering.     There  were  only  six  dressings. 

Eight  days  afterwards  this  man  was  walking  about  on  a 
wooden  leg,  and  has  had  no  suffering  since  ;  I  heard  from  him 
two  years  after. 


CHAPTER  IV. 

The  Dressing  op  Old  Wounds  which  have  or  have  not 
FisTULES. — Wounds  in  the  Neighborhood  of  Natural  Open- 
ings. 

SuEGERY  is  not  simply  operative,  nor  is  it  practised  solely 
for  people  who  present  themselves  with  unbroken  skin.  Is  it 
possible,  when  a  wound  has  been  exposed  to  the  air,  or  when 
it  has  suppurated,  to  purify  it  sufficiently  to  make  antiseptic 
treatment  successful  ? 

Yes,  certainly  ;  and  this  answer  applies  to  both  classes  of 
cases,  —  recent  wounds,  in  which  granulations  have  not  yet 
formed,  and  wounds  which  have  been  suppurating  for  a 
longer  or  shorter  time. 

A  recent  wound,  without  granulations.  —  If  it  is  fresh  and 
still  bleeding,  it  will  suffice  to  give  it  a  bath  in  the  strong 
solution.  If  it  is  very  tortuous,  or  if  it  has  been  exposed  to 
the  air  for  a  long  time,  we  employ  a  still  stronger  solution, 
ten  parts  of  carbolic  acid  to  one  hundred  of  water. 

We  may  even  use  an  alcoholic  solution,  containing  twenty 
parts  of  carbolic  acid  to  one  hundred  of  alcohol.  We  can 
purify  it  sufficiently,  as  large  wounds  in  bones,  complicated 
fractures,  which  have  received  the  advantages  of  antiseptic 
surgery,  abundantly  testify. 

In  case  this  strong  alcoholic  solution  is  employed  in  very 
tortuous  wounds,  as  it  is  a  powerful  caustic,  it  is  well  to  re- 
sort to  a  special  operative  procedure.  Instead  of  injecting  it 
freely  and  at  random,  it  is  a  good  plan  to  guide  it  into  the 
wound  by  the  aid  of  a  sound  or  a  caoutchouc  tube  fitted  to 


64  ~  ANTISEPTIC    SURGERY. 

the  end  of  a  syringe.  By  injecting  thus,  the  quantity  of  the 
liquid  is  graduated  at  pleasure,  and  there  is  no  forcing,  no 
tearing  of  the  areolar  tissue,  no  spreading  on  to  or  burning  of 
all  the  surrounding  parts. 

Wounds  ivhich  have  been  suppurating  fo?'  a  longer  or  shorter 
time. — When,  however,  established  suppurations,  old  wounds, 
and  particularl}'  fistules  which  remain  in  the  operating  field 
are  in  question,  antiseptic  surgery  is  untrustworthy.  It  pro- 
bably happens  in  such  cases  that  the  granulations  retain 
accumulations  of  germs  which  cannot  be  affected  by  the 
fermenticide  action  of  even  a  very  strong  carbolic  injection ; 
and,  little  by  little,  the  wound,  which  at  first  was  exempt 
from  suppuration,  is  invaded  by  it,  as  with  an  ordinary 
dressing. 

Lister  had  experienced  frequent  failures,  when  he  saw 
Volkmann,  of  Halle,  employ  a  method  which  has  since  given 
him  the  best  results. 

It  consists,  in  brief,  in  restoring  the  wound  to  its  primitive 
conditions  of  vitality.  It  is  a  veritable  freshening  practised 
upon  the  entire  surface,  even  into  its  most  remote  recesses. 

To  bring  back  to  its  normal  state  a  wound  which  has  sup- 
purated, we  must  carefully  destroy  all  the  granulations,  all 
the  fungous  excrescences,  which  are  found  upon  its  surface; 
then  it  is  particularly  important  to  penetrate  into  the  fistulous 
passages  and  extirpate  the  granulations  in  them. 

This  is  very  difficult  to  accomplish,  but  it  can  be  done  with 
the  sharp  spoon,  which  Volkmann  has  invented.  This  is  a 
little  cup  of  steel,  very  narrow  and  made  in  various  shapes, 
mounted  upon  a  long  stem,  and  having  a  sharp  edge.  This 
is  carried  into  the  fistulous  tracts,  which  are  then  scraped, 
and  the  detached  granulations  are  brought  out.  Thus  the 
passages  are  swept,  as  it  were,  in  their  entire  extent.  This 
manoeuvre  must  be  insisted  on,  as  a  means  of  destroying  the 


CHLORIDE   OF  ZINC.  55 

greatest  possible  quantity  of  granulations.  Upon  the  wound 
and  in  the  fistules  thus  made  bare,  it  is  necessary  to  exert  an 
antiseptic  action.  For  this  purpose  recourse  is  had  to  a 
powerful  disinfectant  and  caustic,  reserved  for  these  cases, 
the  chloride  of  zinc,  of  which  we  inject  an  eight  per  cent, 
aqueous  solution. 

This  injection  is  gently  thrown  into  the  fistulous  passages, 
without  rupturing  their  walls,  so  as  not  to  introduce  into  the 
areolar  tissue  a  liquid  which  will  produce  gangrene. 

Its  action  would  be  uncalled  for  in  a  widely  open  wound 
which  had  suppurated  at  one  point  only,  if  we  could  excise 
and  detach  all  that  had  suppurated. 

By  the  aid  of  bent  scissors  I  have  succeeded  in  denuding 
the  internal  surface  of  quite  a  large  portion  of  a  small  flap  of 
an  amputation  of  the  thigh,  the  upper  sinus  of  a  white  swell- 
ing of  the  knee.  All  the  parts  having  been  excised,  the  flap 
was  carefully  washed  with  the  strong  carbolic  solution,  and 
the  wound  was  closed  without  delay. 

But  when  we  come  to  fistules,  to  burrowing  sinuses  which 
have  suppurated  for  a  long  time,  the  action  of  chloride  of 
zinc  is  indispensable,  and  it  is  almost  always  efficacious. 

I  have  often  practised  this  method,  and  have  seen  the 
most  remarkable  results  from  it.  I  have  been  able,  for  ex- 
ample, to  render  completely  aseptic  an  immense  purulent  sac, 
which  filled  the  whole  buttock  of  a  girl,  producing  an  inter- 
minable suppuration.  I  laid  open  a  part  of  the  fistula.  The 
washing  out  brought  away  a  handful  of  fungosities  and  some 
dShris  of  bone.  I  then  injected  chloride  of  zinc,  united  the 
parts  with  three  points  of  suture,  and  put  in  a  drain.  Heal- 
ing was  accomplished  in  a  few  days,  and  an  examination  of 
the  patient  months  afterward  revealed  no  return  of  the 
disease. 

One  can  hardly  imagine  how  favorable  to  the  healing  pro- 


56  ANTISEPTIC    SURGERY. 

cess  is  the  condition  in  which  surfaces  are  put  by  this  kind 
of  preparation.  Perhaps  it  is  best  seen  in  resections  of  the 
joints. 

When  the  wound  is  thus  cleansed  it  is  in  the  condition  of 
a  fresh  one.  As  such  it  should  be  treated,  and  will  unite 
according  to  all  the  rules.  No  different  directions  are  re- 
quired from  those  which  are  needed  in  the  case  of  a  recent 
wound. 

The  antiseptic  power  of  chloride  of  zinc  is  such  that  it 
should  be  employed  in  these  cases  and  in  all  in  which  doubts 
of  the  efiicacy  of  carbolic  acid  are  entertained.  Socin,  of 
Bale,  it  is  said,  goes  further,  and  washes  recent  wounds  with 
the  zinc  solution.  We  know  that  as  soon  as  they  are  covered 
with  a  delicate,  white  eschar,  rapid  union  will  easily  take 
place.  I  have  often  employed  this  procedure,  and  like  it  for 
some  large  operations ;  but  I  prefer  to  avoid  it  whenever  it  is 
possible,  because  the  irritation  from  it  is  greater  and  the  pain 
which  follows  the  operations  is  very  severe. 

Wounds  in  the  vicinity  of  natural  orifices. 

The  action  of  chloride  of  zinc,  which  renders  organic  sub- 
stances imputrescible,  is  such  that  it  permits  us  to  make  a 
dressing  which  is  incompletely  antiseptic,  but  still  very  valu- 
able whenever  the  aseptic  dressing  is  not  applicable  in  its 
entirety.  This  is  the  case,  for  instance,  in  operations  about 
the  natural  openings,  —  the  anus,  the  mouth,  etc. 

These  operations  are  made  without  the  spray,  after  prelim- 
inary washings.  After  the  operation  and  before  the  dressing, 
the  lips  of  the  wound  are  carefully  impregnated  with  an 
eight  per  cent,  aqueous  solution  of  chloride  of  zinc,  and  then 
united.  A  drain  is  inserted,  if  possible,  and  then  the  wound 
is  protected  by  folds  of  carbolized  gauze,  or  better  by  linen 
saturated  with  boracic  acid  ointment  and  by  borated  lint. 


CHLORIDE   OF   ZINC-  57 

The  baths  are  of  carbolic  acid  or  chloride  of  zinc  ;  but  we 
must  remember  that  the  antiseptic  action  of  the  latter  lasts 
at  least  two  or  three  days,  and  the  better  way  is  to  leave  the 
dressing  in  place  for  that  time  without  disturbing  it.  Then 
a  carbolic  acid  wash  is  used,  and  the  dressing  is  renewed.  If 
any  portions  of  the  wound  are  not  healed,  we  touch  them 
anew  with  the  chloride.  This  method  may  be  infinitely  varied 
and  accommodated  to  the  requirements  of  each  wound. 

I  cannot,  however,  end  this  chapter  on  the  treatment  of 
parts  which  have  suppurated  without  remarking  that  Lister, 
when  he  finds  diseases  which  have  given  rise  to  suppuration 
of  a  bad  nature,  even  before  the  contact  of  air,  employs  the 
chloride  of  zinc.  I  have  seen  him,  for  example,  in  the  case 
of  a  young  boy,  attacked  with  osteomyelitis  of  the  tibia,  lay 
open  the  periosteum,  and  separate  it  carefully,  especially 
where  he  could  see  drops  of  pus.  Then,  upon  all  the  gaping 
parts,  opened  from  the  knee  to  the  lower  third  of  the  leg,  he 
freely  poured  a  solution  of  chloride  of  zinc  ;  and  this  opera- 
tion was  repeated  the  next  day  at  those  points  where  swell- 
ing still  existed. 

The  reaction  was  less  active  than  one  would  have  expected, 
and  this  child,  who  presented  typhoid  symptoms  of  the  most 
menacing  character,  completely  recovered,  and  preserved  his 
limb  intact. 

I  myself  have  used  the  chloride  successfully,  as  I  shall  ex- 
plain when  treating  of  abscesses. 

5 


CHAPTER    V. 
BoRACic  Acid  and  Unirritating  Dressings. 

In  certain  cases,  where,  on  account  of  extreme  sensitiveness 
of  the  skin,  carbolic  acid  produces  a  kind  of  eczema,  and  in 
others,  where  there  is  little  to  be  discharged  by  drainage, 
antisepsis  may  be  obtained  very  excellently  by  the  aid  of 
boracic  acid.  It  should  be  remembered,  however,  that  this 
is  a  far  less  powerful  agent  than  carbolic  acid,  and  that,  in 
consequence,  much  greater  care  is  necessary  in  using  it. 

Wounds  are  prepared  exactly  as  in  cases  where  carbolized 
gauze  is  employed,  by  a  bath  of  carbolic  acid.  Then  layers 
of  boracic  acid  lint  are  applied  directly  over  the  sutured  sur- 
face, the  undermost  being  wet  in  a  saturated,  aqueous  solu- 
tion of  the  acid,  —  four  parts  to  one  hundred.  The  protective 
can  be  dispensed  with,  as  the  boracic  acid  is  hardly  at  all 
irritating ;  but  in  some  cases  I  employ  it  just  the  same. 

A  sufficient  thickness  of  lint  having  been  applied,  the  im- 
permeable layer  is  added,  and  then  the  dressing  is  firmly 
secured.  If  there  is  a  considerable  amount  of  discharge,  the 
dressing  must  be  renewed  very  often ;  but  ordinarily  we 
employ  this  kind  only  when  there  is  a  moderate  drain,  and 
then  it  has  to  be  renewed  but  rarely. 

Instead  of  a  dry  dressing,  it  is  frequently  preferable  to 
make  use  of  one  in  which  boracic  acid  ointment  is  an  element. 
For  this  purpose,  a  strip  of  lint  is  smeared  with  a  layer  of  this 
salve,  and  is  applied  directly  to  the  wound,  and  over  this  are 
placed  the  folds  of  boracic  lint,  as  has  been  alread}^  described. 


BOEACIC  ACID.  59 

This  unguent  of  boracic  acid  is  very  mild  and  unirritating, 
and,  in  erythema,  it  is  of  conspicuous  service.  In  fact,  I 
have  often  applied  it  all  around  the  wound,  while  using  the 
antiseptic  dressing  of  carbolic  acid,  and  find  that,  in  addition 
to  the  antiseptic  role  which  it  plays,  it  has  a  kind  of  protec- 
tive action  upon  the  wound.  This  is  an  especially  good  dress- 
ing in  all  plastic  operations.  It  is  particularly  useful  at  the 
last  part  of  the  treatment  of  large  wounds,  when  discharge 
has  nearly  ceased,  and  only  superficial  parts  remain  to  be 
healed. 

The  dressing  of  wounds  which  cannot  he  closed. 

If  it  is  not  practicable  to  bring  the  lips  of  a  wound  in 
apposition,  the  antiseptic  method  may  be  used  with  profit, 
without,  however,  getting  the  benefit  of  one  of  its  most 
important  advantages. 

In  such  a  case,  it  is  best  to  close  the  wound  as  far  as  possi- 
ble, and  shield  with  protective  the  portion  which  cannot  be 
united.  At  each  dressing,  scrupulous  care  should  be  taken 
not  to  cause  irritation  by  the  use  of  a  strong  solution  in 
washing. 

If  the  direct,  irritant  action  of  the  carbolic  acid  in  the 
dressing  is  feared,  that  part  of  the  wound  may  be  dressed 
with  the  ointment  of  boracic  acid  and  plentifully  covered 
with  the  lint. 


CHAPTER    VI. 

The  Time  when  the  Antiseptic  Dressing  may  be  omitted. 

There  is  one  condition  of  success  of  so  great  importance 
that  it  is  desirable  to  devote  a  special  chapter  to  it.  It  has 
been  advised  to  omit  antiseptic  precautions  as  soon  as  the 
dangers  which  have  menaced  the  life  of  the  patient  have 
disappeared,  and  not  to  continue  them  to  the  very  end  of 
treatment,  because  the  use  of  carbolic  acid  has  been  thought 
to  retard  the  last  steps  of  the  reparative  process.  This,  how- 
ever, is  a  deplorable  mode  of  procedure. 

Until  cicatrization  is  perfect,  until  the  repair  of  the  wound 
has  been  absolutely  finished,  we  should  persevere  in  the  anti- 
septic protection. 

If  we  desert  a  wound  too  soon,  the  surface,  even  though  it 
be  very  small,  suppurates,  and  this  prolongs  by  just  so  much 
the  work  of  healing.  If  there  happens  to  be  an  opening  into 
the  interior,  a  part  of  the  tract  of  the  tube  unclosed,  suppura- 
tion is  certain  to  occur ;  if  there  is  an  extremity  of  bone  at 
the  bottom,  we  have  osteitis,  partial  necrosis,  and  persistent 
fistulse,  just  as  if  an  ordinary  dressing  had  been  used.  In  a 
foreign  hospital,  where  two  surgeons  applied  the  Lister  dress- 
ing correctly  enough,  I  have  seen  a  series  of  amputations. 
In  one  service,  the  patients  had  pain,  redness,  swelling  of  the 
bone,  and  fistulse :  in  this  service,  as  a  rule,  the  dressing 
was  omitted  after  a  little  time.  In  the  service  of  the  other 
surgeon,  the  appearance  of  the  stumps  was  perfect,  there  was 
nothing  whatever  to  criticise :  in  these  cases,  the  dressing 
was  continued  until  cicatrization  was  complete. 


WHEN   TO   OMIT   THE   DEESSING.  61 

It  is  not  always  necessary  to  maintain  precisely  the  same 
dressing.  In  the  first  part  of  the  treatment,  the  discharge 
becoming  less  and  less  abundant,  according  to  the  progress 
of  repair,  the  dressing  is  changed  more  and  more  rarely. 
Later  any  convenient  dressing  may  be  used,  provided  the 
principles  of  antisepsis  continue  to  be  followed. 

Thus,  boracic  acid  lint  is  very  useful  in  the  latter  stages  of 
the  cure.  It  can  be  put  directly  on  the  wound,  or  separated 
from  it  by  protective.  Before  it  is  applied,  it  is  well  to  wet 
it  in  a  concentrated  solution  of  boracic  acid.  If  there  is  very 
little  discharge,  we  can  dispense  with  the  impermeable  layer 
about  it ;  but,  for  my  part,  I  prefer  to  continue  its  use.  It 
gives  more  security,  and  prevents  the  too  rapid  drying  of  the 
secreted  fluids. 

At  this  period,  the  carbolized  wadding,  or  better  still  the 
salicylic  wadding,  or  the  prepared  jute,  can  be  used  with  ad- 
vantage. In  a  word,  as  the  protection  of  the  wound  is  much 
easier  at  this  time,  we  have  far  more  liberty  in  the  selection 
of  means.  When  healing  seems  to  be  accomplished,. if  there 
is  any  doubt  about  some  corner  of  the  scar  which  is  covered 
with  a  scab,  it  is  wise  to  apply  a  final  dressing,  which  should 
be  left  in  place  without  renewal. 

In  the  course  of  treatment,  the  management  of  the  tubes 
is  sometimes  difficult.  As  a  general  rule,  after  the  first  days 
they  should  be  much  diminished  in  size.  In  fact,  from  this 
time  the  discharge  becomes  inconsiderable ;  but  before  finally 
withdrawing  the  tube,  we  must  make  sure  that  there  is  no 
chance  for  the  accumulation  of  fluids  in  the  deep  parts. 

Many  surgeons  at  the  beginning  of  their  antiseptic  practice 
leave  the  tubes  in  the  wound  too  long,  and  thus  cicatrization 
is  retarded. 


CHAPTER    VIL 

The  Suture  and  Closure  of  Wounds.  —  Superficial  and  Deep 
Sutures.  —  Compression  with  Carbolized  Sponge. 

There  has  been  a  great  deal  of  talk  of  late  about  the  suture, 
and  it  has  even  been  asserted  that  the  especial  kind  of  suture 
is  the  most  original  thing  in  the  Lister  dressing.  One  must 
be  very  ignorant  of  the  method  to  make  such  a  statement. 
Neither  the  single  nor  the  double  suture  is  an  integral  or 
necessary  part  of  an  operation.  There  are  indications  for  it, 
it  may  be  employed,  and  may  be  very  useful  with  particular 
precautions. 

The  more  exactly  and  carefully  the  suture  is  made,  the 
more  rapidly  will  the  wound  heal.  Nevertheless,  it  may 
be  truly  said  that,  with  the  antiseptic  method,  union  is  so 
easy  that  excellent  results  are  obtained,  even  when  coapta- 
tion is  not  perfect. 

Ordinarily  a  superficial  suture  is  made  with  metallic  thread, 
and  Lister  usually  employs  also  the  deep  suture,  but  this  is 
not  his  invariable  practice.  I  have  seen  him  make  a  number 
of  operations  without  resorting  to  it  in  any  way.  Every 
surgeon  of  much  experience  will  easily  understand  the  reason 
of  this.  The  best  of  even  superficial  sutures  compresses  and 
strangles  the  tissues  ;  and,  if  it  is  not  watched,  little  points 
of  suppuration  are  formed.  Lister  habitually  cuts  the  sutures 
early  in  order  to  avoid  this  complication. 

He  uses  coarse  metallic  thread,  particularly  in  making  the 
deep  suture  ;  but  various  other  materials  may  be  employed, 
such  as  carbolized  silk,  catgut,  horsehair,  and  crin  de  Flor- 


FEBB   USE   OF   SUTURES.  63 

ence.  Although,  some  imitators  of  Lister  advise  the  hare-lip 
suture,  I  consider  it  defective  and  useless,  and  in  my  anti- 
septic operations  have  given  it  up  entirely. 

A  very  striking  fact  to  the  surgical  mind  is  the  freedom 
with  which  the  suture  may  be  used.  The  time  has  gone  by 
for  discussion  of  the  question  of  closing  stumps  after  amputa- 
tion. The  suture  is  made  boldly  in  wounds  of  every  kind — 
in  amputations,  wounds  of  serous  membranes,  of  articulations, 
of  the  scalp.  I  have  used  it  after  removal  of  a  sebaceous 
cyst  of  the  head ;  I  have  employed  it  upon  the  scalp  after 
ablation  of  a  lipoma ;  but  I  have  made  it  oftener  after  open- 
ing immense  abscesses,  and  have  obtained  perfect  reunion  of  a 
portion  of  the  opening  after  reducing  the  aperture  of  exit  to 
its  necessary  dimensions. 

Apposition  is  accomplished  very  easily,  and  we  pay  no 
attention  to  certain  precautions  which  were  recommended 
in  former  times.  The  presence  of  ligatures  in  the  wound 
gives  no  concern ;  we  care  very  little  about  removing  every 
drop  of  blood,  for  what  we  desire  is  the  asepticity  of  the 
wound  —  its  surgical  cleanliness,  —  and  this  is  not  interfered 
with  by  the  presence  of  little  clots.  If  the  parts  have  been 
carefully  washed  with  the  chloride  of  zinc  solution  or  the 
strong  solution  of  carbolic  acid,  we  shall  obtain  excellent  re- 
union of  surfaces  which  seem  to  present  real,  though  minute, 
sloughs.  We  get  it,  also,  when,  the  circumstances  not  ne- 
cessitating so  powerful  an  antiseptic  action,  we  use  weak 
carbolic  solutions,  or  even  the  solution  of  boracic  acid. 

The  superficial  interrupted  suture  is  the  most  convenient 
and  the  easiest  to  make.  I  usually  take  the  stitches  more  or 
less  deeply,  according  to  the  depth  of  the  wound. 

When  there  is  difficulty  in  bringing  the  superficial  parts  in 
apposition,  repair  is  greatly  facilitated  by  inserting  some  deep 
sutures.     Lister  advises  their  use  as  follows :  — 


64  ANTISEPTIC    SUEGEEY. 

He  takes  a  needle  threaded  with  coarse  silver  wire,  and, 
introducing  it  at  some  distance  from  the  wound,  he  thrusts  it 
to  the  very  bottom  of  the  solution  of  continuity,  then  carries 
it  from  within  outward  on  the  other  side,  and  brings  it  out  at 
a  point  opposite  that  of  entrance,  and  equally  distant  from 
the  incision.  Then  he  twists  each  end  of  this  wire  around  a 
leaden  plate,  which  serves  to  keep  it  firmly  in  place.  The 
application  of  the  first  plate  is  much  easier  than  that  of  the 
second.  In  order  to  secure  this,  it  is  necessary  to  forcibly 
support  the  lips  of  the  wound,  which  tend  to  gape.  We  are 
thus  sometimes  enabled  to  bring  together  parts  so  far  sep- 
arated that  at  the  first  glance  apposition  seemed  impossible. 

The  suture  being  made,  it  must  be  protected.  Drainage 
should  be  carefully  provided,  not  only  because  accumulation 
behind  the  suture  tends  to  break  it  mechanically,  but  also 
because  excess  of  tension  causes  inflammation  and  suppura- 
tion, which  would  destroy  the  young  products  by  which  re- 
pair is  effected.  This  result  is  easily  obtained  by  the  superior 
method  of  drainage  pursued  by  Lister. 

The  suture,  however,  needs  this  adjuvant  only  at  the  first. 
The  presence  of  a  deep  stitch  demands  particularly  careful 
drainage,  without  which  it  forms  a  decided  barrier  to  the  dis- 
charge ;  and  this  is  one  of  the  principal  reasons  for  employ- 
ing it  only  when  it  is  clearly  indicated. 

The  suture  needs  to  be  protected  from  the  irritant  action 
of  topics,  and  many  fail  in  their  use  of  it  by  disregarding  the 
theory  of  the  protective,  which  they  neglect  to  apply.  Others, 
always  with  some  special  intent,  cleanse  the  wounds,  and  rub 
the  surfaces  with  antiseptic  liquids  ;  and  their  superfluous 
neatness  only  serves  to  prevent  healing.  Still  others,  en- 
tertaining the  same  views,  inject  by  the  tubes  liquid  anti- 
septics, which  they  think  will  favor  healing  and  prevent 
accidents,  and  they  get  the  diametrically  opposite  result  — 


THE   DEEP    SUTURE.  6b 

remarkable  slowness  in  the  reparative  process,  and  failure  of 
union  at  one  or  more  points. 

The  deep  suture  is  necessary  only  when  apposition  is  im- 
possible or  difficult,  and  should  be  continued  the  shortest 
possible  time,  as  it  is  very  likely  to  induce  deep  suppura- 
tion. I  have  seen  extensive  phlegmons  result  from  deep 
sutures  which  were  nearly  useless,  and  which  were  allowed 
to  remain  unnecessarily.  Even  the  superficial  suture  ought 
not  to  be  left  too  long,  and  Lister,  as  I  have  said,  takes 
the  greatest  care  to  cut  at  an  early  day  all  or  part  of  the 
stitches.  He  cuts  them  without  removing  them  immedi- 
ately, for  they  can  still  give  some  support  without  irritating 
or  compressing  the  edges  of  the  wound,  and  can  thus  be  of 
use. 

If,  at  the  level  of  the  deep  stitch,  there  is  a  little  accumu- 
lation of  fluid,  let  out  the  drop  of  pus  with  the  point  of  a 
bistouri,  before  it  provokes  the  ungluing  of  the  flaps. 

Compression  has  been  advocated  as  an  indispensable 
adjuvant  of  the  suture,  and  it  is  doubtless  useful  when  there 
is  a  large  cavity  to  be  filled.  Lister  recommends  an  excel- 
lent procedure,  which  consists  of  compression  with  pieces  of 
sponge  which  have  been  soaked  in  strong  carbolic  water. 

The  employment  of  folds  of  antiseptic  gauze,  skilfully 
applied,  is  also  very  useful ;  but  forcible  constriction  is  en- 
tirely superfluous.  I  have  had  excellent  results  in  some  cases 
where  compression  had  been  so  imperfect  that  the  space 
under  the  flaps  had  filled  with  blood,  and  in  others  where  the 
violent  pain  of  inflamed  parts,  such  as  articulations,  rendered 
all  compression  impossible. 

What  shall  be  the  material  of  the  suture  ?  Whatever  it  is, 
it  is  necessary  to  purify  it  and  soak  it  in  a  strong  carbolic 
solution.     For  most  cases  I  prefer  silver  wire. 

Lister  often  uses  horsehair. 


Q6  ANTISEPTIC    SUEGBRY. 

Carbolized  silk  is  very  manageable,  and  certain  English 
surgeons  employ  it  exclusively. 

Catgut  is  a  good  material  for  suture,  but  it  is  not  free  from 
objections.  It  swells  too  quickly,  and  thus  occludes  the  orifice 
made  by  its  passage,  and  prevents  the  escape  of  liquid  along 
the  thread. 

Le  crin  de  Florence^  the  secreting  organ  of  the  silkworm, 
seems  to  be  an  excellent  material  for  suture. 

Lister  is  in  the  habit  of  putting  the  stitches  quite  near  to- 
gether. It  is  best  to  use  a  needle  of  a  size  a  little  larger  than 
the  thread  requires,  as  by  this  means  there  is  less  irritation  in 
its  track. 

For  the  introduction  of  the  catgut  suture,  it  is  convenient 
to  have  a  special  needle,  like  that  of  Charri^re,  or  of  Bruns, 
or,  what  is  in  my  opinion  the  best  of  all,  a  modification  of  the 
latter  suggested  by  Reverdin,  of  Geneva.  Each  of  these 
needles  has  a  somewhat  spear-shaped  point,  with  a  notch  on 
one  edge,  which  is  closed  by  a  sliding  rod.  The  needle  is 
thrust  through  the  lips  of  the  wound,  the  notch  is  opened 
by  the  withdrawal  of  the  rod,  the  loop  of  catgut  is  inserted, 
the  notch  closed,  and  the  needle  drawn  back. 


CHAPTER    VIII. 

Drainage. 

As  I  have  already  said,  drainage  is  of  paramount  importance. 
The  materials  used  are  various,  but  as  yet  I  have  found 
nothing  better  than  the  tube  of  Chassaignac.  However,  I 
consider  tubes  of  silver,  aluminium,  or  glass  very  valuable  in 
certain  cases,  and  superior  to  those  of  caoutchouc ;  but  as 
satisfactory  specimens  are  not  in  the  market,  I  will  devote  no 
space  to  a  description  of  them. 

Three  principal  modes  of  drainage  are  generally  employed : 
with  the  perforated  caoutchouc  tube  of  Chassaignac ;  ^  with 
catgut,  as  taught  by  Dr.  Chiene,  of  Edinburgh  ;  and  with 
horsehair,  as  proposed  by  White. 

Whatever  may  be  the  material  employed,  it  is  indispensable 
to  understand  certain  conditions  of  drainage.  Wounds 
which  have  been  touched  by  the  powerful  antiseptics,  carbolic 
acid  or  chloride  of  zinc,  discharge  a  considerable  quantity  of 
serosity,  which  thoroughly  saturates  the  dressings  of  the  first 
twenty-four  hours.  It  is  particularly  for  this  discharge  at 
the  outset  that  drainage  is  required,  and,  this  being  pro- 
vided for,  the  quantity  of  the  fluid  which  is  poured  out 
diminishes  rapidly,  and  soon  drainage  is  unnecessary.  If  the 
surfaces  of  the  wound  are  irritated  anew,  a  fresh  discharge  is 
provoked. 

^  Excellent  and  very  inexpensive  drainage-tubes  may  be  made  easily 
of  ordinary  rubber  tubing,  which  can  be  cut  into  pieces  of  any  required 
length.  The  holes  should  be  of  large  size,  and  may  be  made  very  nicely 
■with  ordinary  scissors. 


68  ANTISEPTIC    SURGERY. 

As  these  liquids  are  serous,  slightly  thick,  tinged  with 
blood,  or  only  turbid  with  altered  leucocytes,  their  discharge 
is  easy,  and  one  is  surprised  at  first  to  see  that  a  drain  of 
relatively  small  size  is  sufficient  to  empty  a  large  cavity. 
This  is  illustrated  in  the  case  of  a  drain  placed  upright  in  a 
large  articulation,  even  when  the  liquids  must  run  against 
gravitation. 

But,  although  drainage  does  not  require  much  apparatus, 
at  least  what  it  has  ought  to  be  efficient  and  operate  in 
the  following  manner :  — 

Lister  does  not  place  a  drain  in  a  wound  from  one  end  to 
the  other,  as  Chassaignac  has  taught,  but  inserts  one  or  more 
perpendicularly  from  the  surface  to  the  bottom,  thus  making 
channels  between  the  apposed  surfaces.  But  these  canals 
are  incomplete,  they  are  culs-de-sac ;  and,  as  healing  takes 
place  from  the  bottom  towards  the  surface,  the  tubes  are 
driven  out. 

Every  day  the  drain  is  withdrawn  to  be  cleansed,  and  is 
shortened  to  prevent  the  inner  extremity's  irritating  the  parts 
which  are  healing. 

In  inserting  the  tube  with  the  Lister  fistula-forceps,  no 
force  should  be  used,  lest  it  excite  irritation,  and,  for  the  same 
reason,  it  should  not  project  beyond  the  surface  and  lift  up 
the  dressing.  A  thread  is  fastened  to  the  free  end  for  the 
purpose  of  drawing  it  out. 

As  it  is  important  to  avoid  all  irritant  action  in  the  deep 
parts  of  the  wound,  Lister  carefully  abstains  at  the  time 
of  the  dressings  from  injecting  antiseptics  through  the  drain. 
These  retard  healing  by  partially  preventing  the  union  of  the 
flaps,  and  exciting  suppuration. 

He  even  goes  further.  Ordinarily,  on  the  day  after  an 
operation  he  considers  it  advantageous  to  withdraw  the  drain, 
as  he  does   in    all    following  dressings,  in  order  to  cleanse 


MANAGEMENT   OF   THE   TUBES.  69 

it.  But  when  there  has  been  an  outpouring  of  blood,  and 
the  tube  is  embedded  in  the  clot,  he  advises  not  to  extract  it 
at  the  first  dressing.  This  permits  the  clot  to  organize  and 
to  assist  in  the  repair.  If,  by  the  withdrawal  of  the  tube, 
the  clot  is  broken  or  irritated,  it  is  discharged  in  pieces  with 
the  fluids  of  the  wound.  After  the  clot  is  organized,  it  acts 
as  a  sheath  into  which  the  tube  can  be  returned  when  it  has 
been  cleansed. 

Great  attention  should  be  paid  to  the  selection  and  inser- 
tion of  the  tubes.  They  should  be  large  and  strong,  and  so 
placed  that  their  lumen  may  not  be  effaced ;  they  should 
have  no  elbows,  and  should  not  be  pressed  by  any  point  of 
suture.  In  order  to  fulfil  these  conditions,  it  is  well,  at  the 
time  of  the  operation,  not  to  insert  them  until  the  suture  is 
nearly  complete. 

In  the  subsequent  dressings,  not  only  is  the  tube  to  be 
shortened,  but  it  is  to  be  superseded  by  tubes  progressively 
diminishing  in  size. 

I  am  in  the  habit  of  using  two  tubes  of  small  calibre  side 
by  side,  instead  of  one  of  large  size.  If  need  be,  I  employ  a 
fagot  of  little  tubes,  and  this  method  presents  several  advan- 
tages :  in  the  first  place,  the  capillary  oozing  takes  place  upon 
a  more  extensive  surface,  and  drainage  is  accomplished  more 
easily ;  then,  on  the  next  day,  one  may  remove  a  single  tube, 
and,  if  the  discharge  is  moderate,  leave  it  out,  or,  at  any  rate, 
stop  using  it  after  the  second  or  third  day  ;  finally,  tubes  of 
moderate  calibre  are  much  more  easily  introduced,  even  when 
there  is  quite  a  number.  We  may  use  different  sizes  in  the 
same  bundle. 

For  the  introduction  of  tubes  the  fistula-forceps  is  very 
valuable.  The  tube  being  seized  in  the  direction  of  its 
axis  is  easily  inserted.  Lister  sometimes  even  avails  him- 
self of  the  almost  sharp   extremity  of  the  forceps  to  make 


70  ANTISEPTIC    SURGERY. 

counter-openings  through  which  he  draws  the  rubber 
tube. 

Drainage  with  catgut  was  proposed  by  Dr.  Chiene,  of 
Edinburgh,  who  insisted  upon  the  superiority  of  a  drain 
which  would  not  need  to  be  removed  and  which,  after  it 
had  performed  its  work,  would  be  absorbed.  It  consists  of 
from  six  to  twenty  pieces  of  catgut  in  a  bundle,  which  is 
used  instead  of  the  tube  of  caoutchouc.  The  extremities 
are  allowed  to  pass  slightly  beyond  the  surface  of  the  skin. 
The  fluids  filter  by  capillarity  along  the  threads,  and  after 
some  days  —  the  time  varying  according  to  the  number  of 
threads  employed  —  the  drain  is  absorbed,  and  reunion  is 
accomplished. 

By  this  method  the  deep  irritations  caused  by  displace- 
ments of  the  tube  are  avoided;  and,  far  from  hindering 
repair,  the  foreign  body  in  a  way  assists  it.  Reunion  is 
effected  much  more  rapidly,  and  consequently  recovery  is 
less  protracted.  An  interesting  work  by  Dr.  Jules  Boeckel, 
communicated  to  the  Surgical  Society,  gives  support  to  this 
view.  He  cites  many  very  remarkable  observations  made  in 
cases  of  large  amputations. 

I  think,  indeed,  that  this  method  maybe  applicable  in  some 
cases,  but  I  do  not  consider  it  as  sure  as  ordinary  drainage. 
Having  tried  it  a  few  times,  I  have  noticed  that  it  may  easily 
occasion  unpleasant  accidents.  The  catgut  being  put  in 
place  immediately  swells,  and,  if  the  wound  is  a  little  tortu- 
ous, or  the  orifice  of  exit  of  the  drain  rather  narrow,  the 
opportunity  for  the  escape  of  fluids  is  insufficient,  and  it 
becomes  necessary  to  withdraw  the  drain. 

In  short,  I  believe  that  this  kind  of  drainage  possesses  real 
advantages  as  regards  rapidity  of  cure,  but  it  is  somewhat  de- 
fective as  regards  security.  I  am  more  favorably  disposed 
towards  drainage  with  horsehair,  advised  by  Mr.  White,  of 


HOKSBHAIR  DRAINS.  71 

the  Nottingham  General  Infirmary,  and  adopted  more  recently 
by  Mr.  Lister. 

This  consists  of  a  bundle  of  well-washed  horsehair,  satu- 
rated in  the  strong  carbolic  solution.  The  deep  extremity 
has  a  hair  tightly  wound  about  it  and  tied.  These  drains 
are  used  just  as  are  the  others  which  have  been  described. 
The  fluids  filter  by  capillarity  along  the  hair,  which  does  not 
change  in  size  or  become  clogged,  and  thus  gives  excellent 
drainage.  If  it  does  not  work  well,  it  may  be  removed  and 
reinserted,  and  it  may  even  be  diminished  in  size  without 
removal,  by  withdrawing  a  number  of  hairs.'  I  have  seen 
Lister  use  horsehair  in  almost  the  same  conditions  as  the 
tube  of  rubber,  over  which  it  has  the  advantages  of  drain- 
ing as  well  when  bent  as  when  straight,  and  of  not  con- 
tracting the  bad  odor  which  the  caoutchouc  tubes  sometimes 
acquire. 

Admitting  that  this  material  is  not  generally  employed, 
still  it  is  useful  to  know  of  it,  for  it  is  found  everywhere, 
and  may  be  very  serviceable,  particularly  in  the  country, 
where  the  dressings  must  often  be  made  from  whatever  is  at 
hand. 

While  on  this  subject,  I  may  mention  that  wounds  of  small 
extent  may  be  sufficiently  drained  by  any  substance  which  is 
impermeable  on  account  of  a  smooth  surface,  such  as  bits  of 
taffeta,  gummed  cloth,  rubber  thread  or  ribbon,  etc.,  and 
in  certain  cases  it  is  desirable  to  employ  one  of  these  sub- 
stances. I  emphasize  this,  because  I  have  drained  with  all  of 
them  ;  fine  layers  of  rubber  in  particular  have  rendered  good 
service  in  minor  operations.  In  bundles  they  may  sometimes 
take  the  place  of  a  large  drain. 

Recently  there  have  been  made  absorbable  drains,  per- 
forated and  channelled  like  the  others.  I  have  no  personal 
experience  with  them,  but  I  have  doubts  about  their  coming 


72  ANTISEPTIC    SUEGERY. 

into  general  use,  since  drainage  by  the  resisting  tube  has  so 
many  advantages.^ 

The  surgeon  should  aim  at  reducing  the  time  of  drainage 
to  a  minimum.  M.  Jacques  Reverdin  recently  informed  me 
that  for  some  time  he  has  derived  advantage  from  greatly 
shortening  the  period  of  drainage.  He  more  frequently  re- 
frains from  replacing  the  drain  after  its  removal. 

^  The  drainage-tubes  referred  to  were  introduced  by  ISTeuber,  of  Kiel, 
and  are  made  of  decalcified  bone  or  ivory.  They  disappear  by  absorp- 
tion after  they  have  performed  their  work.  Their  advantages  are  those 
claimed  for  the  catgut  drains.  Esmarch  and  others  have  used  them  ex- 
tensively, and  are  enthusiastic  in  their  praise.  The  method  of  prepara- 
tion is  as  follows  :  — 

Into  a  solution  of  one  part  of  hydrochloric  acid  in  two  parts  of  water 
put  the  drains  which  are  to  be  decalcified,  and  let  them  remain  for  ten 
hours.  Then  remove  them  and  wash  them  in  a  five-per-cent.  carbolic 
solution,  and  preserve  in  ten-per-cent.  carbolic  oil. 

As  these  tubes  are  quite  costly,  it  has  recently  been  proposed  to  use 
the  shafts  of  the  long  bones  of  chickens  for  this  purpose. 


CHAPTER    IX. 

The  Antiseptic  Spray. 

The  production  in  the  atmosphere  in  which  the  operation  is 
performed  of  a  spray  of  carbolized  water  to  protect  the 
wound  from  the  torrents  of  germs  which  the  atmosphere  is 
constantly  pouring  upon  it,  and  which  are  peculiarly  a 
menace  in  hospitals,  constitutes  a  great  advance  upon  Lister's 
first  attempts,  in  which  rapidity  of  operation  and  of  dressing 
under  an  oiled  compress  afforded  only  partial  protection. 

This  procedure  consists  in  enveloping  the  region  of  oper- 
ation in  a  cloud  of  pulverized  carbolic  acid.  It  is  not  in- 
tended, as  many  suppose,  to  cover  the  wound  with  a  fine 
shower  of  the  acid ;  and  it  is  even  well  to  remember  that 
this  rain,  if  prolonged  and  too  directly  applied,  will  irritate 
the  integument  of  the  patient  and  also  the  hands  of  the 
operator. 

The  spray  is  intended  to  destroy  the  germs  and  bacteria 
in  the  air  of  the  operating  region.  Does  it  act  by  directly 
killing  the  germs  ?  Does  it  act  by  driving  them  upon  the 
antiseptic  soil  where  germicide  washes  are  flowing?  It  is 
dijBBcult  to  state  its  mode  of  action,  but  it  is  certain  that  it 
absolutely  changes  the  conditions  of  operations,  and  no  ex- 
periments made  in  circumstances  different  from  those  in  the 
operating  room  can  avail  against  the  actual  experience  of 
surgeons  who  have  tried  antiseptic  surgery  with  and  without 
the  spray. 

Now,  experience  is  very  clear  on  this   point.     We  have 


74  ANTISEPTIC    SURGERY. 

been  able  to  have  uniformity  in  the  results  of  operations 
only  since  the  introduction  of  the  spray  ;  operations  which 
open  great  cavities,  the  recesses  of  which  are  inaccessible  to 
washes,  —  gastrotomy,  herniotomy,  the  opening  of  large  ab- 
scesses, arthrotomy,  —  are  dangerous  and  often  fatal  without 
the  spray. 

The  importance  of  the  spray  is  somewhat  diminished  if 
the  air  is  extremely  pure,  but  it  is  well  not  to  count  too  much 
on  it  in  the  above-named  operations. 

For  operations  in  which  the  traumatic  surface  can  be 
washed,  drenched  with  a  great  deal  of  water,  the  spray  during 
the  operation  is  less  important.  Thus,  surgeons  who  employ 
washes  as  largely  as  Volkmann,  who  pours  the  strong  car- 
bolic solution  upon  the  wounds  from  a  watering-pot,  may 
in  certain  cases  neglect  it ;  but  it  is  always  necessary  to  have 
recourse  to  it  in  the  dressings.  Lister  prefers  not  to  wash 
and  handle  wounds  under  a  current  of  strong  water,  and 
therefore  holds  tenaciously  to  the  spray. 

The  weak  carbolized  water  (one  to  forty)  is  sufficient  for 
the  spray ;  but  it  is  to  be  remembered  that  this  is  true  only 
when  the  hand-apparatus  is  used.  With  the  steam  apparatus, 
which  dilutes  the  jet  of  spray  with  water  from  the  boiler, 
somewhat  stronger  solutions  should  be  employed  (one  to  thirty 
or  forty). 

It  is  very  important  to  use  only  very  pure  carbolic  acid  for 
the  spray,  that  neither  patient  nor  surgeon  may  be  incom- 
moded. There  is  a  great  deal  of  difference  between  the 
carbolic  acids  ;  in  England  and  Germany  the  spray  is  not  at 
all  disagreeable,  as  the  products  employed  are  pure.  If  the 
purity  of  the  acid  permits  the  omission  of  alcohol  from  the 
solution,  the  spray  is  much  less  offensive  to  breathe. 

An  assistant  takes  one  of  the  numerous  spray-producers, 
and  stands  with  it  at  a  distance,  which  is  determined  by  its 


THE  APPARATUS.  75 

power  of  projection,  in  such  a  manner  that  the  wound  is 
always  at  the  point  where  the  cloud  is  the  largest  and  the 
spray  the  finest.  It  is  the  duty  of  the  assistant  to  look  out 
for  the  continuousness  of  the  stream,  to  prevent  it  from  de- 
viating, and  to  keep  it  from  inconveniencing  the  operator  and 
the  patient.  If  there  is  any  interruption  of  the  stream,  he 
must  cover  the  operating  field  with  a  compress  saturated  with 
a  one-to-forty  solution  until  the  jet  can  be  renewed. 

All  spray-producers  are  constructed  upon  substantially  the 
same  principles.  A  powerful  stream  of  air  or  steam  is  driven 
through  a  tube,  whose  orifice  of  exit  is  very  small  and  placed 
just  over  the  mouth  of  a  similar  tube,  the  lower  end  of  which 
is  immersed  in  the  liquid  which  is  to  be  reduced  to  a  spray. 
The  rapid  current  of  air  or  steam  produces  such  a  reduction 
of  pressure  in  the  second  tube  that  the  liquid  rises  in  it ;  and 
as  soon  as  it  emerges  from  the  upper  end,  the  impact  of  the 
air  or  steam  breaks  it  into  a  spray  of  such  fineness  that  the 
process  is  sometimes  extravagantly  called  atomization.  In  an 
apparatus  which  is  driven  by  a  bellows,  the  weak  carbolic 
solution  may  be  used ;  but  in  one  worked  by  steam  power, 
the  strong  solution  is  necessary,  because  the  steam  dilutes  the 
liquid  and  consequently  weakens  it. 

The  simplest  of  the  spray -producers  is  that  of  Richardson, 
the  bellows  of  which  is  worked  by  the  hand.  The  weak 
carbolic  solution  is  employed  in  using  it. 

There  are  some  decided  objections  to  this  apparatus ;  the 
spray  wets  and  chills  the  patient  too  much,  almost  freezes  the 
surgeon's  hands,  and  is  of  too  small  volume  ;  the  assistant 
who  works  it  soon  becomes  fatigued ;  and,  if  it  gets  clogged, 
grave  inconvenience  results.  One  of  these  objections  may  be 
avoided  by  using  a  recently  constructed  improvement  of 
Collin,  in  which  a  little  movable  rod  is  placed  inside  the  suc- 
tion tube,  and  so  arranged  that  by  pushing  it  upwards,  any 


76  •  ANTISEPTIC    SUBGEEY. 

obstruction  to  the  flow  of  liquid  through  the  aperture  of  exit 
is  instantly  removed. 

It  is  very  inconvenient  to  use  several  of  these  machines  at 
once,  and  so  I  have  had  Collin  make  me  a  spray-producer  on 
the  same  principle,  with  three  beaks  instead  of  one.  The 
volume  of  spray  from  this  triple  apparatus  is  sufficient  for  a 
large  operation,  especially  if  the  beaks  are  made  to  diverge. 
If  one  of  the  tubes  should  chance  to  become  obstructed,  the 
spray  will  still  be  abundant,  and  no  trouble  ensues.  The 
bellows  is  very  large  and  is  worked  by  the  foot  without 
fatigue.  Unfortunately  this  apparatus  wets  the  parts  a  good 
deal,  and  chills  them  after  a  time,  even  when  hot  liquids  are 
used. 

The  bellows  apparatuses  may  properly  be  used  in  small 
operations  and  in  dressings,  and  they  have  the  advantage  of 
■  those  driven  by  steam  in  requiring  no  expenditure  of  time  in 
preparation  and  no  consumption  of  alcohol.  The  fineness  of 
the  tubes  sometimes  occasions  inconvenience,  as  the  least  dirt 
chokes  them.  The  end  of  the  suction  tube  which  is  immersed 
in  the  fluid  should  be  furnished  with  a  little  linen  filter,  and 
a  similar  device  should  be  employed  at  the  free  extremity  of 
the  bellows,  to  prevent  the  particles  of  all  sorts,  which  are 
always  floating  in  the  air,  from  being  drawn  into  the  tube. 

For  all  major  operations  the  steam  apparatus  is  indispensa- 
ble. It  keeps  at  work  a  long  time  without  attention,  and  the 
spray  which  it  furnishes  is  perfectly  continuous  and  finer  than 
that  from  the  air  machines. 

Lister's  steam  spray-producer  is,  in  all  respects,  an  excel- 
lent instrument,  and  its  perfection  is  an  abundant  excuse  for 
the  complexity  of  its  structure.  It  consists  of  a  boiler  with 
a  safety-valve,  the  escape-tube  of  which  is  provided  with  a 
spout  through  which  the  stream  of  steam  is  projected.  The 
lower  tube  meets  this  at  an  acute,  instead  of  a  right,  angle,  — 


STEAM  SPRAY-PEODUCERS.  77 

an  arrangement  upon  which  Lister  lays  great  stress.  The 
boiler  is  heated  by  a  spirit-lamp,  the  circular  wick  of  which 
heats  a  tube  at  the  extremity  of  which  burn  the  vapors  of 
alcohol  which  are  set  free.  There  is  an  arrangement  by 
means  of  which  the  flame  can  be  increased  or  diminished, 
according  as  more  or  less  steam  is  needed.  In  the  English 
hospitals  the  lamp  is  often  surrounded  by  a  wire  gauze.  A 
vessel  for  the  carbolized  water  is  fastened  in  front  of  the 
lamp.  This  apparatus  is  inconveniently  heavy  and  very 
costly ;  but  it  gives  so  very  fine  a  spray  that  the  operator  is 
not  wetted  at  all,  and  it  runs,  according  to  the  volume  of 
spray,  two  hours  or  more,  that  is,  all  the  time  necessary  for  a 
capital  operation. 

M.  Collin,  our  ingenious  instrument-maker,  has  made  me 
an  apparatus  which,  it  seems  to  me,  could  be  improved  only 
by  borrowing  all  the  constituent  parts  of  Lister's  spray- 
producer.  It  presents  some  modifications,  some  perfection  of 
detail,  and,  best  of  all,  is  so  much  less  expensive  that  the 
most  impecunious  hospital  can  afford  to  buy  it. 

It  differs  materially  in  form  from  Lister's.  The  boiler  is 
spherical,  that  shape  being  chosen  on  account  of  the  ease  of 
heating  and  the  greater  strength.  Like  all  the  steam  appar- 
atuses it  has  a  boiler,  which  is  heated  by  an  alcohol-lamp. 
At  the  upper  part  of  the  boiler  are  a  sort  of  funnel  which 
gives  an  opportunity  to  see  when  the  boiler  is  full,  and  thus 
makes  the  employment  of  a  movable  funnel  unnecessary;  a 
safety-valve  ;  two  tubes  for  the  exit  of  steam,  which  can  be 
moved  up  and  down  so  as  to  permit  a  variation  in  the  direc- 
tion of  the  stream.  These  tubes  have  no  stop-cocks,  but,  by 
a  very  simple  mechanism,  close  when  they  are  lifted  well 
up.  Each  meets  at  an  acute  angle  the  tube  by  which  it 
draws  up  the  carbolized  water  which  is  placed  in  the  reser- 
voir in  front.     At  the  lower  end  of  each  of  the  immersed 


78  A2JITISEPTIC    SURGERY. 

tubes  is  a  little  sponge,  wliich  filters  tlie  liquid  which  passes 
into  them. 

The  spray  is  very  fine,  does  not  wet,  as  that  furnished  by 
most  machines  does,  and  covers  a  large  area.  The  arrange- 
ment which  gives  two  beaks  instead  of  one  I  have  long  con- 
sidered very  important,  not  because  there  is  need  of  two 
simultaneous  streams,  but  because  we  want  to  be  able,  when- 
ever one  of  the  beaks  becomes  clogged  in  the  course  of  the 
operation,  to  open  the  other  immediately  without  moving  the 
apparatus.  Several  manufacturers  in  England  and  elsewhere 
have  since  adopted  the  same  arrangement. 

If  the  apparatus  is  started  with  a  full  boiler,  it  will  go 
more  than  two  hours  uninterruptedly.  It  runs  with  a  low 
pressure,  but  is  tested  at  a  very  high  one  in  order  to  avoid 
the  danger  of  explosion.  It  is  quite  large  enough,  and  yet  is 
not  very  heavy. 

The  wick  of  the  lamp  is  sheathed  in  two  metallic  tubes,  so 
arranged  that  the  flame  can  be  increased  or  diminished  at 
pleasure.  Thus,  when  the  escape-tubes  are  closed,  a  very 
little  heat  can  be  furnished,  just  enough  to  maintain  the 
pressure.     The  lamp  is  filled  from  the  side. 

At  the  beginning  of  the  daily  visit,  we  fill  the  boiler  with 
hot  water,  supply  the  reservoir  with  strong  carbolic  solution, 
screw  on  the  stopper,  and  light  the  lamp.  We  carefully 
watch,  and  lower  the  beak  when  pressure  is  got  up,  or  allow 
even  more  pressure  than  is  absolutely  necessary,  lest  it  fall 
too  rapidly  and  the  stream  be  imperfect. 

If  we  expect  to  use  the  machine  for  a  long  time,  and  the 
pressure  is  very  high,  we  may  well  lower  the  wick,  and,  after 
a  few  minutes,  raise  it  again. 

Generally  the  stream  of  steam  has  a  characteristic  blue 
color  when  it  pulverizes  well ;  and,  by  pinching  the  rubber 
suction-tube,  its  thorough  performance  can  be  assured. 


l!  !» 


^ 


80.  ANTISEPTIC    SUKGEIIY. 

Great  pains  should  be  taken  to  keep  the  reservoir  well 
supplied  with  carbolic  solution. 

If  there  arise  any  indications  of  failure  of  the  steam,  the 
lamp  should  be  instantly  extinguished  to  avoid  burning  the 
boiler.  However,  by  lifting  it,  after  a  little  experience  one 
can  tell  by  its  weight  when  the  boiler  is  nearly  empty,  and 
then  it  should  be  replenished  at  once.  For  this  purpose,  the 
lamp  being  extinguished,  the  steam  is  let  off  by  the  valve  and 
both  the  tubes,  and  then  one  can  unscrew  the  stopper  with- 
out danger  of  burning  himself.  In  replenishing  the  boiler, 
only  hot  water  should  be  used  ;  in  this  way  we  avoid  ruining 
the  boiler,  pressure  is  got  up  much  more  quickly,  and  the 
consumption  of  alcohol  is  diminished. 

When  we  have  finished  using  the  apparatus,  it  is  well  to 
completely  empty  the  boiler,  that  we  may  know  exactly  the 
quantity  of  water  to  put  in  the  next  time. 

The  boiler  of  my  spray-producer  holds  about  a  liter,  the 
lamp  about  half  a  liter. 

If  the  apparatus  is  needed  for  a  short  dressing  only,  it  is 
sufficient  to  half  or  even  quarter  fill  the  boiler :  the  less 
water  there  is,  the  sooner  will  the  steam  be  generated. 

Some  surgeons  have  thought  it  necessary  to  fill  the  atmos- 
phere of  their  amphitheatres  with  a  thick  cloud,  others  have 
set  up  costly  high-pressure  machines  ;  but  I  think  my  spraj^- 
producer  suffices  for  all  wants.  It  is  placed  upon  a  table  at 
the  distance  of  two  meters  from  the  field  of  operation,  which 
it  envelops  in  a  cloud  which  neither  obscures  vision  nor  wets. 
Being  constructed  on  the  principles  so  ably  expounded  by 
Lister,  it  cannot  fail  to  give  satisfaction. 

Finally,  it  is  worth  while,  in  the  interest  of  economy,  to 
bear  in  mind  that  such  a  spray-producer  is  not  only  valuable 
for  the  special  service  it  was  designed  to  perform,  but  is  of 
great  use  in  making  a  spray  for  inhalation  and  in  purifying 
and  disinfecting  the  wards. 


AMERICAN   SPEAY-PEODUCBRS. 


81 


Among  the  spray-producers  of  American  manufacture  one 

of  the  most  reliable  is  that 


CODMAN  &  SHURTLEFF 


■■==:~i^^^^=|: 


Fig.  2. 


represented  in  the  accom- 
panying cut.  It  has  a 
spherical .  boiler  which  is 
tested  by  a  hydrostatic 
pressure  of  more  than  one 
hundred  pounds  to  the 
square  inch.  The  tubes 
are  of  brass,  with  plati- 
num nozzles,  and  can  be 
readily  removed  and  re- 
placed, so  that  tubes  for 
other  than  antiseptic  pur- 
poses may  be  substituted.      In  the  lower   tube  there   is  a 

clearer  which  is  easily  operated.     The  lamp-jacket  confines 

the    heat  under  the    boiler 

and  protects  the  flame  from 

currents  of  air,  but  does  not 

prevent  a  view  of  the  flame. 

The  lamp  is  provided  with 

a    flame-regulator     and    an  » 

extinguisher,  which  can  be 

operated  from  the  outside, 

and   it   can   be  replenished 

with  alcohol  safely  while  in 

operation.      This  apparatus 

is  advertised  to  run  between  codman  &  shuStleff; 

BOSTON. 

three  and  four  hours  with  Fig.  3. 

one  filling  of  the  boiler.     It  costs  twenty-five  dollars. 

A  much  cheaper,  but  quite  efiicient  spray-producer  is 
shown  in  Fig.  3.  The  essential  points  are  substantially  like 
those  in  the  machine  just  described.  The  price  of  this  is 
twelve  dollars. 


82 


ANTISEPTIC    SURGERY. 


Fig.  4. 


Fig.  5. 


Dr.  Weir's  apparatus, 
pictured  in  Fig.  4,  is  a 
modification  of  Lister's, 
constructed  to  avoid  the 
great  cost  of  the  latter, 
without  sacrificing  any- 
necessary  details.  It  is 
furnished  for  fifteen  dol- 
lars. 

Another  ingenious  and 
inexpensive  instrument 
is  that  devised  by  Dr. 
Hanks,  and  shown  in 
Fig.  5.  The  spray  can 
be  projected  at  any 
angle.  The  antiseptic 
fluid  is  not  drawn  up  by 
the  force  of  the  steam. 


but  is  allowed  to  flow  down  from  the  elevated  tank,  the 
force  of  the  stream  being  regulated  by  a  stop-cock. 


CHAPTER    X. 

Catgut. — Its  Uses  as  a  Ligature,  for  Drainage,  as  a  Suture, 

AND   IN   THE   PLUGGING   OF   BONY   CaVITIES. 

Oke  of  the  most  remarkable  points  in  the  practice  of  Lister 
is  the  employment  of  carbolized  catgut.  This  is  certainly 
one  of  the  important  triumphs  of  surgery. 

As  has  been  remarked  previously,  a  foreign  body  in  the 
tissues  induces  suppuration,  if  it  is  charged  with  germs ;  but 
if  it  is  aseptic,  it  may  remain  an  indefinite  time  without 
exciting  the  formation  of  pus. 

At  the  outset,  struck  with  the  disadvantages  of  ligatures 
which  needed  to  be  discharged  and  which  excited  suppura- 
tion in  the  depths  of  wounds.  Lister  made  experiments  to 
determine  the  effects  of  ligatures  impregnated  with  fermenti- 
cide  substances,  particularly  of  hemp  or  silk  soaked  in  a 
concentrated  solution  of  carbolic  acid. 

Although  the  first  results  were  favorable,  Lister  thought 
that,  if  he  could  find  a  substance  which  would  unite  with  the 
tissues  or  even  be  absorbed  into  them,  the  result  would  be 
incomparably  better.  The  idea  then  occurred  to  him  to  em- 
ploy catgut  which  had  undergone  fermenticide  preparation, 
and,  after  a  number  of  trials,  he  achieved  success.  This 
ligature  has  properties  so  valuable  that  it  is  necessary  to 
detail  the  mode  of  preparation. 

Catgut  is  made,  as  is  well  known,  from  the  intestines  of  the 
sheep.  We  select  cords  of  various  sizes  as  they  are  found 
in  the  market,  and  it  is  well  to  know  that  they  should  not  be 
very  old  and  dry,  and  that  those  made  in  some  countries  are 


84  AjSTISeptic  surgery. 

superior  to  those  made  in  others.  The  most  solid  and  resist- 
ant are  made  in  France. 

In  the  condition  in  which  we  find  it,  the  cord  cannot  stand 
the  tying  of  a  knot ;  it  will  often  break.  Thus  the  prepara- 
tion which  it  receives  gives  it  strength,  and  at  the  same  time 
deprives  it  of  germs. 

It  is  steeped  for  from  four  to  six  months  in  the  following 
mixture : — 

Crystals  of  carbolic  acid  are  dissolved  in  one  tenth  part 
their  weight  of  water,  and  five  parts  of  olive-oil  are  added, 
and  the  whole  is  intimately  mixed.  The  cords  are  placed  in 
this  emulsion,  where  they  first  swell,  soften,  and  become 
opaque.  After  some  time  the  thread  becomes  firmer,  trans- 
parent, and  more  solid.  The  knot  made  now  is  very  strong, 
does  not  break  like  one  in  a  cord  which  has  not  been 
prepared,  and  does  not  slip  as  it  does  when  oil  only  has  been 
used  in  the  preparation. 

It  is  a  very  curious  fact  that  if,  instead  of  adding  water  to 
the  carbolic  acid,  we  dissolve  it  directly  in  the  oil,  the  effect 
upon  catgut  soaked  in  it  is  totally  different,  for  it  becomes 
soft  and  slippery  as  soon  as  it  is  wet,  and  is  of  no  use  what- 
ever.i 

Although  a  good  deal  of  time  is  consumed  in  the  process 

1  Lister  devoted  his  inaugural  address  as  president  of  the  Clinical 
Society  of  London,  on  the  28th  of  January,  1881,  to  the  subject  of  the 
catgut  ligature,  and  gave  the  results  of  his  experiments  to  find  a  method 
of  preparation  which  should  obviate  the  necessity  of  consuming  so  much 
time  as  the  above  plan  requires,  and  still  produce  a  trustworthy  article. 
He  recommends  the  following  process  :  — 

Dissolve  1  part  of  chromic  acid  in  4,000  parts  of  distilled  water,  and 
add  to  the  solution  200  parts  of  pure  carbolic  acid.  Into  this  liquid  im- 
mediately put  catgut  equal  in  weight  to  the  carbolic  acid.  At  the  end  of 
forty-eight  hours,  the  gut  is  sufficiently  prepared.  Then  it  is  removed 
from  the  solution,  dried,  and  placed  in  one-to-five  carbolic  oil.  It  is  then 
fit  for  use. 


CATGUT   LIGATURES.  85 

of  preparation,  we  get  in  return  a  thread  which  remains  good 
indefinitely,  if  it  is  kept  immersed,  and  even  may  be  said  to 
improve.  Thread  thus  prepared  is  in  every  respect  fit  to  be 
left  in  the  midst  of  the  tissues.  This  substance  possesses,  in 
fact,  the  property  both  of  remaining  without  injury,  and  of  dis- 
appearing little  by  little.  It  seems  that  it  identifies  itself  with 
the  tissues,  or  is  absorbed.  Experiments  upon  animals  have 
shown  that,  after  a  certain  time,  only  the  knot  can  be  per- 
ceived and  distinguished  from  the  artery  and  the  peripheral 
parts  where  the  ligature  was  left.  We  thus  see  that  this 
ligature,  instead  of  provoking  the  process  of  elimination,  the 
result  of  which  is  the  decay  of  the  thread,  in  no  way  irritates 
the  parts  where  it  is  found.  Instead  of  cutting,  it  supports 
them  ;  it  sustains  them  at  the  first  moment  of  the  ligation, 
and  will  continue  to  do  so  for  a  long  time.  This  result  is 
obtained  when  the  ligature  has  been  placed  at  the  extremity 
of  a  severed  artery,  as  in  a  stump,  and  also  when  it  has  been 
put  around  an  artery  in  its  continuity. 

In  a  stump  the  ligature,  being  cut  short,  remains,  and  does 
not  prevent  union  by  first  intention.  Even  if  it  has  been  put 
upon  tissues  particularly  susceptible  to  external  irritation,  it 
is  proved  that  they  do  not  resent  its  presence.  Lister  has 
had  occasion  to  close  wounded  veins  with  catgut  sutures,  and 
the  stitches  have  not  been  thrown  off. 

Keith,  of  Edinburgh,  so  well  known  as  one  of  the  most 
successful  ovariotomists,  told  me  that  he  constantly  and  freely 
used  catgut  ligatures  in  the  peritoneal  cavity,  that  he  had 
thus  left  a  considerable  number  of  them  at  a  time,  and  that 
no  accident  had  ever  happened  in  consequence,  even  before 
he  employed  the  antiseptic  method.  Many  others  have  fol- 
lowed his  example,  and  I  among  them. 

I  have  already  had  a  large  experience  with  catgut,  having 
employed  it  particularly  as  a  ligature  in  every  way,  and  it 


86  ANTISEPTIC    SUEGERY. 

has  never  failed  to  fulfil  the  promise  of  the  theory  ;  and  I 
insist  upon  this  fact,  — that  one  derives  from  it  many  other 
effects  than  that  of  a  simple  ligature  in  a  wound. 

It  strangles  the  tissues  sufficiently  to  arrest  bleeding  and 
yet  does  not  kill  them,  if  the  wound  is  kept  aseptic.  If  it 
is  poisoned,  casting  off  of  the  ligature  is  common. 

For  example,  when  one  practises  castration,  he  can  ligate 
the  cord  en  masse,  close  the  wound  with  sutures,  and  the  end 
of  the  cord  will  not  be  thrown  off.  In  1876  I  operated  at 
the  HOpital  Necker  for  the  removal  of  a  very  large  sarcoma 
of  the  testicle,  and  in  seventeen  days  the  patient  was  com- 
pletely cured  without  the  discharge  of  the  ligature. 

In  the  operation  for  strangulated  hernia  I  have  a  number 
of  times  tied  the  omentum  in  little  parts,  and  then  reduced 
it  or  left  it  in  the  wound.  The  portions  of  omentum  which 
were  thus  constricted  were  not  eliminated,  and  the  rapid 
union  of  the  lips  of  the  wound  was  not  interfered  with. 
(An  excellent  method  for  omental  hernia,  founded  upon  this 
principle,  has  been  published  by  Dr.  Chiene.) 

This  is  the  principle  which  has  been  applied  by  ovarioto- 
mists,  who  divide  the  pedicle  into  several  parts,  tie  each  with 
catgut,  and  drop  it  back  into  the  abdomen.  Some  close  the 
abdomen  with  the  complete  suture,  others  drain  it,  as  in  all 
operations  by  the  Lister  method. 

It  is  evident  that  the  soft  parts  may  be  constricted  by 
catgut  ligature  without  mortifying.  One  reservation  must 
be  made, — the  parts  compressed  must  neither  be  too  volumi- 
nous nor  have  been  previously  mortified. 

In  one  hernia  operation  I  saw  one  ligature  out  of  seven 
thrown  off  with  a  little  tuft  of  omentum,  and  the  final  heal- 
ing was  retarded  some  days.  But  here  the  last  part  of  the 
dressing  was  not  aseptic ;  and  when  the  dressing  is  rigorously 
aseptic,  this  occurrence  is  not  at  all  likely  to  take  place. 


DISAPPEARANCE   OE   CATGUT.  87 

Catgut  must  necessarily  be  employed  for  the  sutures,  for 
it  renders  valuable  service  when  used  in  certain  condi- 
tions. But  there  is  room  for  discussion  as  to  these  cases, 
on  account  of  the  lack  of  solidity  and  also  the  swelling  of  the 
thread. 

We  know  that  the  substance  which  forms  catgut  is  rapidly 
absorbed  in  the  tissues.  Numerous  experiments  have  been 
made  on  this  point,  and  we  now  consider  as  utterly  incorrect 
the  view  that  there  takes  place  a  veritable  organization  of 
the  animal  cord,  which  begins  by  swelling  and  appropriating 
young  elements,  and  then  disappears  from  the  midst  of  the 
tissues,  leaving  new  vessels  in  the  place  which  it  occupied. 

Whatever  may  be  the  method  of  this  disappearance,  it  is 
actually  effected,  and  Chiene  has  derived  from  it  his  method 
of  drainage  so  eminently  favorable  to  the  rapid  union  of 
wounds. 

Another  application  of  catgut  is  in  the  arrest  of  hemorrhage 
at  the  bottom  of  osseous  cavities  which  bleed  freely.  Lister 
has  reported  among  others  the  following  case:  in  trephining 
a  skull  in  the  median  line  he  opened  the  superior  longitudi- 
nal sinus.  He  crowded  pieces  of  catgut  into  the  hole  made 
by  the  trephine  until  it  w^as  completely  full,  and  the  blood 
was  stayed.  The  catgut  disappeared  gradually,  and  the 
patient  recovered  without  accident. 

In  the  same  manner  we  insert  in  the  osseous  canal  after 
amputation  a  bunch  of  catgut  to  stop  the  bleeding,  which 
being  accomplished,  the  catgut  is  left  in  place,  and  no  harm 
follows. 

In  each  of  the  special  chapters  the  uses  of  catgut  are  men- 
tioned. It  should  be  known  that  it  may  be  employed  like 
other  threads  ;  when  it  is  well  prepared  it  is  simple  and  easy 
to  manage.  I  am  in  the  habit  of  employing  thread  of  quite 
large  size,  considering  it  useless  to  take  the  fine,  as  thread  of 


88  ANTISEPTIC    SURGERY. 

any  size  disappears.     I  make  three  knots  instead  of  two,  to 
guard  against  the  possible  slipping  of  the  second. 

I  have  described  the  manufacture  of  catgut  with  some 
minuteness,  because  the  commercial  article  is  often  a  medi- 
ocre product,  made  hastily,  with  cord  of  poor  quality,  without 
the  addition  of  water  to  the  oil,  or  without  a  lapse  of  time 
sufficient  for  its  preparation.  To  this  I  attribute  most  of  the 
objections  falsely  made  to  the  employment  of  this  very  valu- 
able material. 


CHAPTER    XL 

Influence  of  the  Method  upon  the  Phenomena  of  Repair.  — 
The  Absence  of  Suppuration. — The  Beginnings  of  Experi- 
mentation.—  Absence  of  Micro-organisms. 

We  have  considered  the  principles  of  the  method  and  the 
details  of  the  dressing.     What  are  the  results  ? 

At  first  thought  it  would  seem  to  be  easy  to  decide  this 
question  by  a  reference  to  statistics.  Of  these  we  have 
already  valuable  elements,  as  will  be  seen  in  another  chapter. 
But  the  method  is  quite  new ;  it  has  been  misapplied  and 
perverted  by  many  who  have  scant  knowledge  of  it,  and  j^et 
publish  in  its  name  results  which  are  barely  improvements  on 
those  of  other  methods  ;  and  even  the  method  of  the  last 
years  is  much  surer  than  that  of  a  decade  ago,  and  the  figures 
of  the  former  period  are  not  to  be  compared  with  those  of 
recent  times.  From  this  it  is  evident  that  the  data  are  insuffi- 
cient, and  besides  one  can  easily  make  whatever  he  wishes  of 
statistical  figures. 

But  we  have  more  precious  elements,  of  which  the  first  is 
the  unanimous  opinion  of  those  who  have  thoroughly  adopted 
the  practice  of  antiseptic  surgery.  There  is  but  one  voice 
concerning  the  general  progress  of  surgery ;  every  one  says,  — 

"  The  ranks  of  my  patients  were  formerly  decimated  by 
surgical  complications,  especially  by  purulent  infection.  I 
have  seen  these  complications  disappear  from  my  wards.  Not 
only  to-day  do  I  no  longer  fear  purulent  infection,  septicae- 
mia, but  I  practise  as  I  choose  all  the  operations  which  are 
most  hazardous  to  patients,  —  upon  the  bones,  articulations, 

7    . 


90  ANTISEPTIC    SURGERY. 

and  veins, — and  I  see  no  harm  result.  Hospitalism  is  a  word 
which  has  lost  its  meaning.  It  gives  so  little  inquietude 
that  one  may  defy  it  in  his  wards." 

These  statements,  coming  from  eminent  men  of  large  ex- 
perience, are  calculated  to  excite  us,  but  it  would  take  a  long 
time  to  convince  us  of  the  reality  of  these  marvellous  results 
and  of  much  other  progress,  if  it  were  not  easy  at  the  first 
trial  to  comprehend,  avouch  for,  and  even  explain  them  by 
the  study  of  the  phenomena  of  repair.  We  no  longer  seek 
an  explanation  in  the  enthusiasm  of  the  inventor  or  his  disci- 
ples and  in  the  allurement  of  novelty. 

Careful  observation  made  in  our  hospitals,  as  well  as  in 
Edinburgh,  London,  Denmark,  Germany,  indeed,  all  over  the 
world,  prove  to  the  most  incredulous  the  marvellous  change 
in  the  phenomena  of  repair,  which  is  in  a  way  the  criterion 
of  the  worth  of  the  method. 

The  phenomena  of  repair. 

From  the  first  essays  of  the  method,  the  observer  is  greatly 
impressed  with  the  totally  new  progress  of  the  reparative  pro- 
cess. Formerly,  in  all  wounds  of  any  importance,  the  follow- 
ing phenomena  were,  in  varying  degrees,  observed  constantly: 
change  in  the  appearance  of  wounds  and  the  surrounding 
parts,  swelling  of  the  edges,  suppuration,  great  tenderness, 
tension,  and  pain  ;  at  the  same  time  more  or  less  severe  trau- 
matic fever. 

If  the  surface  of  the  wound  was  extensive,  suppuration 
was  abundant,  and  the  dressings  always  exhaled  a  more  or 
less  fetid  odor,  particularly  if  the  fluids  had  been  retained  a 
little  while.  If  clots  of  blood  had  accumulated  in  the 
wound,  after  remaining  a  time  they  were  detached  and  formed 
a  magma,  which  was  fetid  from   the   suppuration  which  at- 


RAPIDITY   OF   REPAIR.  91 

tended  its  removal.  Fragments  were  left  behind  which  seri- 
ously interfered  with  repair  and  invited  complication. 

Then  the  period  of  inflammation  passed  away,  suppuration 
diminished,  granulations  sprang  up  at  all  points  where  union 
by  first  intention  had  not  taken  place.  Cicatrization  was  ob- 
tained only  with  more  or  less  lengthy  suppuration,  involving 
either  a  part  or  the  whole  of  the  wound,  with  divers  varia- 
tions during  the  continuance  of  the  reparative  process. 

But  with  the  antiseptic  dressing  nothing  is  the  same.  All 
the  parts  which  are  brought  together  by  suture  unite.  From 
the  depths  of  the  wound  drains  off  abundant  serum,  blackish 
at  first,  but  later  only  turbid  or  yellowish.  This  discharge 
diminishes  little  by  little,  and  soon  becomes  insignificant. 

Around  the  wound  there  is  no  swelling  or  redness.  On 
the  eighth  da.j  a  stump  presents  the  aspect  and  color  which 
were  observed  on  the  first. 

If  clots  of  blood  have  been  enclosed  under  the  flaps  or 
between  the  lips  of  the  wound,  instead  of  disintegrating,  of 
provoking  suppuration,  of  hindering  union,  they  take  part  in 
the  phenomena  of  repair.  Their  surface  takes  on  a  very 
characteristic  grayish  tint.  They  adhere  to  the  lips  of  the 
wound,  some  effort  is  necessary  to  detach  them,  and,  after 
some  days,  if  they  are  scratched,  the  surface  bleeds,  new  ves- 
sels having  formed  in  them.  According  to  Professor  Lister, 
they  become  organized  where  they  lie.  Surely,  the  operator 
cannot  doubt  their  presence  in  the  wound. 

In  the  dressing  there  are  no  infecting  fluids,  no  bad  odor. 
At  no  time  after  their  application  do  the  pieces  of  dressing- 
emit  any  odor  but  that  which  is  characteristic  of  the  resin 
and  carbolic  acid  which  they  contain. 

The  phenomena  of  repair  in  all  tissues,  especially  in  those 
far  below  the  surface,  are  accomplished  with  inconceivable 
rapidity. 


92  ANTISEPTIC    SURGEEY. 

I  have  observed  this  so  many  times  that  I  am  surprised 
when  this  rapidity  does  not  obtain ;  but  I  was  much  struck 
in  seeing  at  the  Edinburgh  Infirmary,  in  1875,  a  wound 
twenty  centimeters  long,  from  the  ablation  of  a  breast,  healed 
in  nineteen  days.  Furthermore,  a  woman  in  whom  the  ex- 
ternal iliac  had  been  ligatured  was  well  in  less  than  three 
weeks.  At  the  same  time,  Lister  told  me  of  a  resection  of 
the  knee,  with  complete  cicatrization  in  fifteen  days.  Analo- 
gous facts  are  common  to-day. 

We  used  to  see  wounds  repair  differently,  according  to 
the  tissues  which  were  involved.  Now,  whether  the  wound 
involves  bone,  serous  membranes,  vessels,  or  areolar  tissue, 
repair  occurs  with  remarkable  uniformity. 

In  all  these  wounds  we  leave  great  numbers  of  ligatures, 
which  do  not  become  detached,  but  become  incorporated 
with  the  tissues,  and  support  instead  of  destroying  them. 

Traumatic  fever  is  generally  of  slight  importance,  being 
reduced  to  its  minimum  ;  but  it  usually  is  present,  though 
appreciable  only  with  the  thermometer.  There  is  very  little 
reaction. 

All  this  has  an  important  bearing  on  the  theory  of  trau- 
matic fever.  I  have  expressed  the  view  that  nothing  sup- 
ports the  idea  that  traumatic  fever  has  a  septicsemic  origin. 
It  results  from  a  local  irritation,  reacting  more  or  less  upon 
the  economy  through  the  nervous  system.  Putrid  liquids 
accumulate  on  the  surface  of  a  wound  and  irritate  it ;  remove 
them  and  irritation  diminishes,  the  fever  subsides.  It  does 
not  disappear  completely,  because  there  remain  some  parts 
which  are  irritated  by  the  air,  the  dressings,  and  the  dead 
elements  which  are  thrown  off. 

If  it  were  true  that  traumatic  fever  depended  upon  poison- 
ing by  putrid  materials,  it  would  not  exist  when  the  wound 
was  absolutely  aseptic.     I  have  elsewhere  presented  this  ar- 


ABSENCE    OP   SUPPURATION.  93 

giiment,  and  many  others,  which  seem  to  me  equally  con- 
vincing against  the  septicsemic  origin  of  traumatic  fever.  I 
v^^as  very  happy  to  find  my  opinion  in  conformity  with  that  of 
Professor  Lister. 

I  have  already  pointed  out  a  remarkable  resemblance  be- 
tween the  thermic  results  of  the  dressing  of  Lister  and  those 
of  the  wadded  dressing  of  Alphonse  Guerin,  which  also  di- 
minishes the  intensity  of  the  traumatic  fever,  and  said: 
"  Reduce  to  their  minimum  the  phenomena  of  elimination, 
mortification,  and  local  irritation,  and  you  will  diminish  to  its 
minimum  traumatic  fever." 

That  which  is,  indeed,  the  most  characteristic  point  in  the 
method  of  Lister  is  the  reduction  to  a  minimum  of  the  phe- 
nomena of  elimination. 

Not  only  the  united  lips  of  a  wound  are  consolidated,  but 
the  walls  of  a  traumatic  cavity  come  together  and  unite  under 
very  slight  pressure  ;  and  suppuration,  which  is  always  pres- 
ent when  the  cavities  of  wounds  heal  by  granulation,  does 
not  take  place.     Even  an  abscess  cavity  does  not  suppurate. 

The  liquid  which  drains  from  the  wounds  is  so  different 
from  common,  laudable  pus  that  the  two  should  not  be  con- 
founded. That  which  shows  this  method  of  repair  to  be  the 
most  perfect  is  the  absence  of  waste  of  young  cells,  which,  in 
wounds  treated  by  ordinary  methods,  are  thrown  off  in  great 
numbers. 

The  wound  under  the  antiseptic  dressing,  says  Lister,  gives 
no  pus.  At  first  it  discharges  a  sanguinolent  liquid,  then  a 
darkish  serum,  then  serum  which  is  either  transparent  or 
cloudy.  There  are  in  it  granular  corpuscles,  but  not  the 
masses  of  well-formed  globules  which  characterize  ordinary 
pus.  In  this  fluid  the  globules  are  infrequent,  modified, 
with  no  definite  characteristics. 

However,  to  the  naked  eye,  the  appearance  of  the  liquid  is 


94.  ANTISEPTIC    SURGERY. 

not  always  the  same :  sometimes  it  is  viscid,  and  resembles 
synovia  ;  at  other  times  it  is  yellovt^ish,  and  looks  a  little  more 
like  pus,  and  may  till  up  the  drainage  tubes. 

If  the  wound  is  irritated  and  badly  drained,  the  liquid, 
always  scanty,  is  even  more  like  laudable  pus,  without  its 
creamy  consistency.  If  the  cause  of  the  irritation  is  removed 
in  the  course  of  the  day,  the  cloudy  serum  reappears.  This 
is  seen  in  a  recess  of  a  badly  protected  wound,  about  a  stitch 
which  is  too  tight,  in  a  cavity  with  too  narrow  an  opening  of 
exit.     It  should  be  watched  for  and  remedied  immediately. 

But  if,  in  the  absence  of  these  causes,  you  see  on  the  sur- 
face of  a  wound  a  layer  of  true  pus,  creamy  and  abundant, 
you  may  be  sure  that  germs  have  penetrated  and  the  dress- 
ing is  infected.  The  patient  is  not  necessarily  injured  seri- 
ously, but  he  is  endangered,  and  he  will  recover  by  the  pro- 
cess of  suppurative  reparation,  the  ideal  of  ancient  surgery. 
You  may  be  sure,  then,  that  true  antiseptic  surgery  has  not 
been  accomplished. 

The  more  nearly  the  phenomena  of  repair  approach  the 
type  we  have  indicated,  the  simpler  is  reunion ;  and  it  is  in 
these  cases  that  we  see  clots  at  the  bottom  of  a  wound  not 
disintegrating,  but  taking  a  gray  tint,  contracting  a  little,  and 
becoming  penetrated  with  vessels.  If  they  themselves  do 
not,  properly  speaking,  organize,  they  contribute  to  repair ; 
they  serve  as  a  woof  for  the  weaving  in  of  the  neighboring 
vessels,  which  put  out  buds,  and  soon  their  substance  is  vas- 
cular. Their  presence  assists  repair.  Lister  counts  so  much 
upon  this  phenomenon  that,  when  he  scoops  out  great  cavities 
in  bone  which  cannot  collapse,  he  scrapes  the  fleshy  granula- 
tions in  the  vicinity  in  order  to  fill  up  the  osseous  cavity  with 
clots  ;  because,  when  he  does  so,  living  tissues  occupy  it  much 
more  quickly,  and  healing  is  greatly  accelerated. 

The  absence  of  the  phenomena  of  irritation  during  repair 


FREEDOM  FROM  SUFFERING.  95 

permits  each  element  to  live  in  the  midst  of  a  wound  as  well 
as,  perhaps  better  than,  in  the  depths  of  tissues  which  have 
not  been  uncovered.  This  is  what  explains  how  repair  is  so 
rapid,  so  exempt  from  complications,  in  the  case  of  serous 
membranes  and  viscera,  which  are  prone  to  inflame.  One 
operates  in  conditions  more  favorable,  certainly,  than  those 
of  subcutaneous  surgery. 

It  is  so  true  that  inflammation  does  not  occur,  that  the  few 
operations  where  it  is  needed  are,  in  a  measure,  incompatible 
with  antiseptic  surgery.  In  the  operations  for  pseudarthrosis, 
the  resections  produce  almost  no  formation  of  callus,  and  the 
antiseptic  method  must  be  abandoned  after  a  few  days  in 
order  to  obtain  irritation  enough  to  provoke  the  required 
exudation. 

Repair  is  singularly  regular.  With  the  old  surgery  it 
could  be  said  that  each  new  wound  had  its  own  physiog- 
nomy ;  that  wounds  differed  absolutely  in  appearance  and 
progress,  according  to  the  tissues  involved.  Here,  all  are 
alike :  the  same  pallor  of  the  tissues,  the  same  constant 
union,  the  same  non-purulent  discharges,  with  some  differ- 
ences as  regards  the  amount  of  liquid  and  the  greater  or  less 
duration  of  drainage,  according  to  the  size  of  the  traumatic 
surfaces.  But  all  points  in  the  wound  have  the  same  aspect. 
The  uncovered  parts  have  a  certain  grayish  tint,  which  is  not 
particularly  pleasing  to  the  eye ;  and  they  preserve  this  hue 
until  healing  is  completed,  if  they  are  not  molested  with 
untimely  friction. 

One  of  the  most  fortunate  phenomena  is  the  freedom  from 
suffering.  Partly  on  account  of  the  anaesthetic  action  of  the 
carbolic  acid,  much  more  because  of  the  absence  of  irritation, 
the  spontaneous  pain  is  slight,  and  contact  with  the  wound  is 
not  distressing.  The  patients  do  not  complain  at  having 
stumps  and  immense  traumatic  surfaces  dressed.     If  there  is 


96  ■  ANTISEPTIC    SURGERY. 

pain  before  the  operation,  the  sedation  is  marvellous ;  and  we 
may  say  that  one  of  the  most  striking  characteristics  of  ser- 
vices in  which  the  antiseptic  method  is  employed  is  the  ap- 
pearance of  the  patients,  who,  free  from  fever  and  pain,  eat 
and  sleep  and  recuperate  their  powers  in  perfect  quietude. 

Local  complications  are  absent.  There  is  repair  without 
pus,  without  fetor,  with  reduced  fever,  without  pain,  without 
exhaustion  of  the  wounded.  There  are  no  general  complica- 
tions, as  we  shall  see  in  the  following  chapter.  The  most 
fortunate  surgeons  used  to  consider  erysipelas  and  septicse- 
mia  possible :  certain  operations  predisposed  to  these  dis- 
eases to  such  an  extent  that  they  were  specially  feared.  But 
now,  whatever  the  man,  the  medium,  or  the  operation,  com- 
plications have  disappeared ;  for  even  erysipelas,  which  some- 
times shows  itself,  is  shorn  of  its  grave  character. 

Just  as  the  wounds  present  a  very  remarkable  appearance, 
the  scars  also  are  extremely  interesting.  They  are  neat,  reg- 
ular, and  linear.  Stumps  which  have  not  suppurated  are 
supple.  There  are  no  cicatricial  adhesions,  retractions,  or 
indurations.  In  regions  which  are  accessible  to  inspection, 
operations  leave  scarcely  a  trace. 

What  I  observed  in  Professor  Lister's  service  I  have  seen 
in  my  own ;  and  1  have  been  deeply  impressed  with  the  fact 
that  I  obtained  the  same  results  immediately.  I  was  cer- 
tainly far  behind  the  perfection  of  the  master  ;  and  yet,  from 
the  beginning,  I  found  the  same  modification  of  the  processes 
of  repair.  I  think  it  very  important  to  put  this  fact  on  rec- 
ord, and  for  this  reason  I  revive  to-day  the  history  of  the  first 
operations  which  I  made,  in  1875  and  1876,  in  the  temporary 
hospital,  with  a  strict  method.  These  operations  were  va- 
ried, and  in  all  I  obtained  union,  in  all  the  surgical  fever  was 
slight,  in  none  was  there  a  discharge  of  true  pus.  I  may  be 
allowed  to  cite  the  amputation  of  a  leg  at  the  upper  third. 


ILLUSTRATIVE   CASES.  '  97 

absolutely  cicatrized,  epidermis  included,  in  twenty-four  days. 
There  was  a  large  clot  in  the  stump,  and  yet  repair  was  not 
impeded. 

An  enormous  myxoma  of  the  parotid,  larger  than  a  tur- 
key's egg,  in  a  man  of  twenty-eight,  years  of  age.  On  the 
fifteenth  day  there  was  a  little  epidermic  ulceration.  On  the 
eighteenth  day  T  showed  him  to  the  Surgical  Society,  abso- 
lutely healed.  There  never  was  a  drop  of  pus  or  puriform 
liquid  in  the  wound,  only  turbid  serum.  His  temperature 
did  not  exceed  38°  C. 

A  lipoma  under  the  scalp  was  removed  from  a  man  of  fifty 
years.  It  had  the  dimensions  of  a  hen's  egg,  and  lay  in  the 
left  fronto-parietal  region.  A  great  deal  of  blood  was  dis- 
charged into  the  cavity  after  the  suture  was  made  ;  but  in 
spite  of  this,  there  was  no  suppuration,  and  cicatrization  was 
complete  in  nine  days. 

Trephining  of  the  greater  trochanter,  attacked  with  osteitis 
in  a  man  of  forty-eight,  who  presented  immense  fistulas,  com- 
mencing at  the  iliac  crest  and  descending  beneath  the  tro- 
chanter. The  fistulse  were  cleansed  and  injected  with  chloride 
of  zinc  ;  the  very  extensive  wound  of  the  operation  was  closed 
first,  and  all  the  great  fistulas  were  closed  in  a  month.  The 
dressing  was  then  omitted,  and  the  patient,  who  had  been 
confined  to  his  bed  for  eight  months,  with  suffering  so  intense 
as  to  make  walking  impossible,  stepped  off  without  difficulty. 
I  made  him  go  to  bed  again,  because  I  found  that  one  of  the 
numerous  fistulse  low  down  had  been  neglected.  It  was 
superficial,  but  pretty  long  and  well-organized,  for  I  made 
carbolic  injections  without  success.  I  decided,  after  some 
days,  to  cleanse  this  fistula  by  the  proceeding  previously  de- 
scribed, to  make  a  counter-opening,  and  put  in  a  drain.  In 
a  few  days  it  was  perfectly  closed,  and  the  patient  was  cured, 
a  result  which  I  verified  eight  months  afterwards. 


98  ,  ANTISEPTIC    SUEGEKY. 

This  man  had  a  long  and  interesting  history.  He  suffered 
continually  without  respite  up  to  the  day  of  operation.  I 
found  nothing  in  the  joint  to  explain  this  pain  and  his  in- 
ability to  walk.  The  greater  trochanter  was  a  little  increased 
in  size  and  tender  on  pressure.  A  multitude  of  constantly 
suppurating  fistulse  had  followed  as  many  abscesses,  but  the 
bone  could  be  reached  at  only  one  point.  To-day  all  the 
fistulse  are  closed,  and  walking  occasions  no  pain. 

In  this  case  I  made  a  free  incision,  and  removed  a  large 
prominence  of  the  trochanter,  the  tissue  being  soft  but  not 
carious.  Excepting  the  point  where  two  large  drains  passed, 
the  whole  wound  united.  Two  very  firm  sutures  provoked 
around  them  the  formation  of  four  or  five  drops  of  pus, 
which  I  evacuated.  The  great  wound  never  gave  any  dis- 
charge but  serum,  at  first  dirty,  then  yellowish,  and  a  little 
viscid  after  some  days.  The  traumatic  fever  was  insignifi- 
cant, the  temperature  never  reaching  38°  C,  and  in  a  month 
everything  was  cicatrized.  This  large  wound,  complicated 
with  traumatism  of  bone,  behaved  like  the  wound  made  in 
the  removal  of  the  parotid  tumor,  which  I  have  just  re- 
ported. 

Besides  the  major  operations  made  in  the  first  six  months 
of  my  experience,  I  reported  a  number  of  others  of  minor  im- 
portance, not  only  in  the  way  of  congratulating  myself  on 
having  seen  them  escape  so-called  hospital  complications,  but 
also  to  note  that  the  same  mode  of  repair  is  shown  in  small  as 
in  large  operations. 

Two  amputations  in  the  same  patient,  one  of  the  great  toe, 
the  other  of  the  second,  rapidly  and  perfectly  healed,  in  spite 
of  a  diseased  and  injured  skin,  and  the  fact  that  the  ligatures 
were  left  in  the  wound, 

I  have  practised  upon  two  patients  denudation  of  veins  for 
varix,  after  the  manner  of  Rigaud,  which  consists  in  exposing 


OPERATION   FOR    VARIX.  99 

a  large  venous  trunk  and  isolating  it  upon  a  foreign  body, 
and  I  was  able  to  note  from  the  very  first  entire  absence  of 
reaction.  But  I  was  especially  struck  at  seeing  that  these 
isolated  veins,  lifted  up  on  sounds,  did  not  die  under  the 
dressing.  The  first,  which  was  slender,  was  well  denuded, 
and  placed  upon  a  rubber  tube.  I  supposed,  at  the  first 
dressing,  that  the  tube  would  not  sufficiently  hold  the  vein, 
and  therefore  substituted  for  it  a  gum  sound.  The  vein  did 
not  break  ;  a  little  blood  was  effused  around  it.  At  the  end 
of  a  fortnight,  tired  out,  I  removed  the  sound.  The  wound 
cicatrized  rapidly,  and  when  the  patient,  cured  of  his  ulcer, 
got  up,  I  saw  with  regret  that  the  vein  was  perfectly 
pervious. 

In  the  second  patient,  finding  a  large,  thickened  vein,  and 
foreseeing  the  same  inconvenience,  I  denuded  it  extensively 
and  raised  it  up  on  two  sounds.  It  died  no  more  than  the 
other.  The  effusion  filled  up  the  wound  around  the  vein, 
which  I  liberated  at  the  expiration  of  twelve  days.  Never- 
theless, the  vein  was  obliterated.  The  patient,  rapidly  cured 
of  his  ulcer,  walked  off,  provided  with  a  cloth  stocking  and 
feeling  very  comfortable. 

In  these  two  cases  it  seemed  that  the  dressing,  which  al- 
lowed the  tissues  to  retain  their  maximum  of  vitality,  pre- 
vented mortification  of  the  walls  of  the  veins.  Therefore, 
recognizing  this  absence  of  reaction,  this  ease  of  operation 
upon  the  veins,  I  have  devised  another  operative  procedure, 
for  I  never  had  more  than  moderate  confidence  in  the  harm- 
lessness  of  the  original  procedure  without  the  Lister  spray. 
Rigaud,  having  thrice  opened  veins,  lost  three  patients  by 
purulent  infection. 

My  operation  is  vastly  more  simple,  much  more  rapid  in  its 
healing,  and  sure  to  effect  obliteration.  It  consists  in  tjing 
the   great  venous   trunks  with   catgut,  which  is  left  in  the 


100  ANTISEPTIC    SURGERY. 

wound.  I  have  as  yet  •performed  this  but  once,  but  it  seems 
destined  to  give  the  best  results.  It  is  much  easier  than 
Rigaud's  and  is  surely  infinitely  less  dangerous. 

I  have  made  yet  other  operations  vs^ith  excellent  results  — 
enucleation  of  the  eye,  which  I  dressed  with  boracic  acid  ;  ex- 
tirpation of  a  neuroma  in  the  stump  of  a  fore-arm. 

In  another  class  of  cases  I  have  had  capital  proof  of  the 
influence  of  the  method,  as  illustrated  in  the  opening  of  an 
abscess  of  the  neck,  under  the  sterno-mastoid,  following 
angina.  The  patient,  who  was  in  a  dangerous  condition, 
being  chloroformed,  I  opened  the  abscess  with  antiseptic  pre- 
cautions, and  injected  the  cavity  with  weak  carbolic  solution, 
afterwards  using  the  strong.  In  eight  days,  a  great  purulent 
sac  which  had  been  freely  opened  was  completely  closed,  and 
after  the  primary  evacuation  there  was  scarcely  any  discharge 
of  pus. 

In  the  first  edition  of  this  book  I  reported  the  preceding 
cases,  and  I  repeat  the  record  now  in  order  to  show  exactly 
what  every  surgeon  can  accomplish  in  his  first  attempt  by 
strict  observance  of  the  method.  And  yet  my  conditions 
were  unfavorable,  my  assistants  were  inexperienced,  I  was 
obliged  to  disturb  myself  with  pharmaceutical  details  ;  but  I 
contributed  an  element  of  appreciation  which  was  of  value. 
The  service  of  the  temporary  hospital  in  which  I  had  this 
experience  contained  forty-five  beds  in  an  old  building  badly 
located,  of  the  healthfulness  of  which  I  never  had  a  good 
opinion.  During  these  six  months  there  were  six  cases  of 
erysipelas,  but  not  one  occurred  in  a  patient  who  had  the 
antiseptic  dressing.  Three  of  them  were  brought  in  ;  three 
broke  out  in  the  wards,  —  one  in  a  patient  who  had  a  little 
wound  of  the  head  without  any  dressing,  the  two  others  in 
men  who  had  ulcers  of  the  leg.  One  of  these  had  a  severe 
erysipelas  which  started  up  in  an  almost  cicatrized  wound  ; 


NO    WOUND    COMPLICATIONS,  101 

the  other,  with  an  immense  ulcer  of  the  leg,  had  erysipelas  in 
the  face,  and  died. 

Thus  it  will  be  seen  that  the  surroundings  were  far  from 
favorable  for  operations  upon  the  veins  or  the  scalp. 

In  the  four  years  which  have  slipped  away  since  then  I 
have  had  a  large  experience.  I  have  made  my  operations  in 
one  after  another  of  the  Paris  hospitals,  some  of  which  are 
not  of  the  best.  I  did  a  large  amount  of  work  in  the  Lariboi- 
siere,  and  also  in  the  Necker.  I  have  operated,  or  had 
charge  of  the  operations  for  the  most  part,  in  the  following 
hospitals :  Pitie,  H8tel-Dieu,  Beaujon,  Maison  de  Sante,  En- 
fants  Malades,  Sainte-Eug^nie,  Bicetre,  Saltpetri^re,  Mater- 
nit^.  Everywhere  the  results  have  been  the  same.  Some  of 
the  surgeons  have  continued  to  employ  the  method,  more  or 
less  rigorously  —  Professors  Guyon,  Verneuil,  Panas,  MM. 
de  Saint-Germain,  Le  Dentu,  Terrier,  Perrier,  and  many 
others.  Even  those  who  have  not  been,  in  my  opinion,  suffi- 
ciently rigorous,  have  made  such  progress  that  their  surgery 
has  changed  its  appearance.  Those  who  have  been  more 
strict  have  had  results  identical  with  my  own. 

In  spite  of  the  importance  of  this  practice,  I  present  no 
statistics,  for  I  consider  mine  insufficient.  All  that  I  can  say 
is  that,  when  the  method  has  been  rigorously  pursued,  /  have 
not  had  a  single  case  of  wound  complication,  either  in  an 
operation  patient  or  in  one  who  has  been  seriously  injured. 
I  have  seen  neither  erysipelas  nor  purulent  infection,  and  I 
have  dared  to  do  operations  which  no  one  before  has  ven- 
tured in  France  ;  and  when  I  have  applied  the  method  to 
some  wounded  men  and  not  to  others,  it  has  been  used  in  the 
most  serious  of  the  cases. 

I  may  remark  here  that,  in  describing  the  indications  for 
the  principal  operations,  I  shall  report  cases  from  my  own 
practice. 


102  ANTISEPTIC    SUEGERY. 

I  must  not  close  this  chapter  without  saying  a  word  on  a 
most  important  question.  In  the  midst  of  the  laborious  pur- 
suit of  antiseptic  surgery,  I  have  had  little  leisure  for  study- 
ing the  capital  theoretic  question,  of  noticing  the  presence  or 
absence  of  living  beings  in  protected  wounds.  Having  no 
confidence  in  my  personal  competence  in  this  respect,  I  will 
not  report  my  investigations.  I  have  made  a  few  investiga- 
tions in  ordinary  conditions,  with  negative  results  ;  but  this 
small  number  of  observations  is  not  a  sufficient  foundation 
for  an  opinion. 

Lister,  a  singularly  competent  and  strict  observer,  found 
none  of  the  organisms  of  putrefaction  in  the  fluids  of  his  own 
dressings.  His  pupils  also  have  searched  for  the  micro-organ- 
isms which  characterize  putrefaction,  and  have  not  succeeded 
in  finding  them.  I  am  aware  that  some  other  authors,  par- 
ticularly Ranke,  are  said  to  have  found  them  in  the  best- 
made  dressings  ;  but  even  in  these  cases,  the  micro-organisms 
did  not  resemble  those  of  common  wounds,  either  in  form, 
number,  or  activity. 

On  the  whole  we  may  assert,  upon  the  authority  of  compe- 
tent observers,  that  microbes  are  absent  in  wounds  treated  in 
this  manner.  There  is  still  need  of  careful  observations  to 
rigorously  and  absolutely  demonstrate  their  absence ;  but 
their  presence  has  been  affirmed,  rather  than  demonstrated, 
by  the  other  investigators,  who  have  found  them  to  be 
infrequent  and  peculiar. 

Are  we  to  believe,  with  those  who  have  found  micro- 
organisms under  the  dressing,  that  their  conditions  of  ex- 
istence are  so  profoundly  modified  that  they  have  become 
innocent  and  incapable  of  doing  harm?  This  idea  is  defensi- 
ble. The  history  of  these  creatures  is  not  yet  written  ;  their 
varieties  may  be  infinite,  and  we  scarcely  know  those  condi- 
tions of  their  existence  which  are  the  most  simple  and  the 


MICROSCOPIC   OBSERVATIONS.  103 

easiest  to  observe.  Investigators  of  high  competence  must 
decide  at  last  as  to  the  theory  and  microscopic  observa- 
tions. 

One  is  apt  to  think  that  it  is  sufficient  to  take  a  look  in 
order  to  judge  ;  but  it  is  necessary  to  knoM^  hovr  to  look,  and 
this  is  a  very  difficult  matter. 


CHAPTER   XII. 

General  Results  of  the  Dressings. — Wound  Complications. — 
Some  Figures.  —  Lister.  —  Saxtorph.  —  Volkmann. 

The  attentive  reader  of  the  preceding  chapter  should  be 
able  to  foresee  the  immediate  and  remote  consequences  of  the 
application  of  the  method.  If  it  is  true  that  almost  the  en- 
tire traumatic  surface  is  immediately  closed,  that  healing  is 
most  rapid,  that  the  phenomena  of  elimination  are  reduced  to 
a  minimum,  that  the  phenomena  of  putrefaction  are  sup- 
pressed, it  is  extremely  probable  that  the  accidents  of  wounds 
will  be  infinitely  rare.  This,  in  fact,  is  what  all  affirm  who 
have  tried  the  method  in  a  serious  way.  The  modification  is 
most  striking  in  the  case  of  purulent  infection,  pyaemia.  We 
see  it  disappear  at  once  from  certain  services  where  it  had 
been  constantly  observed ;  and  this  was,  according  to  Lister, 
the  first  benefit  of  the  application  of  the  method  in  Glasgow. 
Hospital  gangrene  also  disappeared,  as  has  been  remarked  in 
a  number  of  institutions  where  it  was  previously  endemic. 

Quite  naturally,  prolonged  suppurations  and  putrid  infec- 
tion are  suppressed.  Erysipelas  is  perhaps  less  influenced,  for 
it  is  sometimes  observed  in  spite  of  the  dressing  ;  but,  never- 
theless, it  is  infinitely  less  frequent  than  with  other  methods, 
and,  as  authors  say,  it  is  less  alarming  in  its  manifestations, 
even  in  times  when  it  is  epidemic. 

These  results  are  not  obtained  merely  by  a  few  advocates 
of  the  method,  which  has  made,  in  spite  of  active  opposition, 
many  more  converts  than  can  be  enumerated.  It  has  given 
the  same  results  in  every  place  where  it  has  been  adopted. 


LISTER   IN  GLASGOW.  105 

And,  in  this  connection,  it  is  only  fair  to  note  that  the  pnb- 
lislied  statistics  in  many  countries  and  hospitals  of  the  more 
or  less  fortunate  modifications  which  have  been  made  are  far 
from  giving  an  idea  of  the  success  v^^hich  is  attained  by  the 
rigorous  method. 

The  complete  transformation  of  surgery  is  evident.  Doubt- 
less there  are  many  who  deny  the  light ;  but  none  v^ho  care- 
fully study  the  published  facts  or  well-conducted  services  can 
long  resist. 

Is  it  necessary,  in  order  to  judge  of  these  results,  to  gather 
into  a  common  statistical  table  all  the  facts  which  have  been 
reported,  and  add  them  up  ?  That  would  give  the  most 
erroneous  idea  possible.  The  method  is  too  new  to  be  tested 
in  that  manner. 

Unlike  figures  should  not  be  reckoned  together;  and  if, 
nevertheless,  I  do  so  in  this  chapter,  it  is  for  the  purpose  of 
showing  how  the  same  surgeon,  in  the  same  service  and  at 
the  same  period,  has  abruptly  modified  his  surgery. 

The  first  and  most  striking  example  is  that  taken  from  the 
practice  of  Lister.  He  inaugurated  antiseptic  surgery  in 
Glasgow  in  a  hospital  situated  in  the  midst  of  emanations 
from,  a  graveyard  so  crammed  with  bodies  that  they  were 
hardly  covered  with  earth.  The  windows  of  the  wards  for 
the  wounded  were  most  directly  exposed  to  these  effluvia. 
No  change  was  made  in  the  situation  of  this  hospital,  which 
was  notorious  for  its  surgical  complications. 

Lister  compares  his  results  before  the  antiseptic  period  with 
those  obtained  during  it.  The  method  was  in  itg  infancy,  its 
success  was  far  from  being  complete ;  and  yet  one  can  easily 
see  the  first  transformations  which  were  wrought  in  the  midst 
of  circumstances  which,  as  he  has  vividly  shown,  comprised 
all  the  special  causes  of  unhealthfulness. 

Being  unable  to  find  the  records  of  three  consecutive  years 


106  ANTISEPTIC    SURGERY. 

preceding  the  antiseptic  period,  he  takes  only  two  years.  The 
antiseptic  period  includes  1867,  1868,  and  1869. 

In  the  first  period  there  were  thirty-five  large  amputations, 
with  sixteen  deaths ;  in  the  second,  forty  amputations,  with 
only  six  deaths.  Thus  the  mortality  for  amputations  was 
reduced  from  forty-five  to  fifteen  per  cent. 

The  result  was  curious,  especially  in  view  of  the  fact  that 
the  mortality  after  the  least  of  these  large  operations  was 
always  due  to  the  dominant  influence  of  hospitalism.  Thus, 
in  the  first  period  there  were  twelve  amputations  of  the  upper 
extremity,  with  six  deaths ;  in  the  second,  twelve  amputations 
of  the  upper  extremity,  with  only  one  death,  and  this  was  in 
the  case  of  a  boy  who  was  operated  on  in  spite  of  the  mani- 
fest existence  of  purulent  infection. 

But  this  was  only  in  the  beginning  of  his  method,  and  the 
progress  has  been  immense  since  then.  In  Edinburgh  he 
had  only  one  case  of  purulent  infection  in  six  j^ears,  this 
following  ablation  of  the  breast ;  he  had  in  the  same  period 
not  a  case  of  hospital  gangrene.  As  regards  erysipelas,  it 
was  very  rare,  was  less  severe,  and  often  was  situated  far 
from  the  wound.  He  had  in  his  wards  only  two  cases  of 
tetanus,  and  both  of  these  were  in  patients  who  had  putrefy- 
ing wounds. 

In  the  least  healthy  wards,  Lister  for  four  years  suspended 
the  annual  washing  which  had  been  customary  up  to  that 
time.  He  brought  in  extra  beds  ;  there  were  sometimes  as 
many  as  three  or  four  children  in  a  bed.  He  often  had 
seventy  patients  for  fifty-five  beds.  The  cleanliness  of  the 
patients  was  only  relative.  Aside  from  antiseptic  neatness, 
they  were  dirty  enough.  Think  of  dressings  remaining  in 
place  six  or  eight  days.  "  From  the  sesthetic  point  of  view 
they  were  foul,  from  the  surgical  they  were  clean." 

After  his  removal  to  London,  Professor  Lister  continued  to 


saxtoeph's  statistics.  107 

observe  the  same  very  happy  results.  He  reserves  all  these 
facts  for  a  general  statistical  table,  when  they  have  become 
very  numerous  ;  but  it  is  proper  to  state  that  the  success  of 
his  practice  has  in  no  respect  diminished. 

Again,  we  find  the  same  results  in  the  practice  of  Saxtorph, 
of  Copenhagen,  one  of  the  first  in  Europe  to  employ  the 
Lister  method  in  a  great  hospital  service,  and  an  ardent  advo- 
cate of  it. 

In  a  hospital  whose  insalubrity  every  now  and  then  became 
so  marked  that  purulent  infection  swept  off  his  patients,  even 
after  an  amputation  of  a  finger,  he  made  in  1876  the  follow- 
ing operations,  the  statistics  of  which  he  himself  furnished 
me  with  :  — 

Eleven  resections  of  the  knee,  three  deaths. 

Nineteen  amputations  of  the  thigh,  six  deaths. 

Fifteen  resections  of  the  hip,  six  deaths. 

Eight  resections  of  the  wrist,  two  deaths. 

Seven  resections  of  the  elbow,  one  death. 

Six  resections  of  the  shoulder,  three  deaths. 

Ten  extractions  of  foreign  bodies  from  joints,  freely  laid 
open,  one  death. 

Twenty-two  Syme's  amputations  of  the  foot,  seven  deaths. 

Eleven  extirpations  of  the  calcaneum,  four  deaths. 

But  this  was  only  the  commencement,  the  transition  from 
a  state  of  insalubrity  to  a  condition  of  health,  with  all  the 
gropings  of  a  beginner  in  a  method ;  and  his  results  are  very 
much  nearer  perfection  to-day. 

Saxtorph  has  not  reported  all  his  statistics,  the  figures  of 
which  would  be  enormous,  but  he  has  informed  us  of  the 
sum  total  of  his  results  after  resections,  and  especial  attention 
is  asked  to  the  teaching  of  this  brief  statement. 

It  is  easy  to  follow  the  improvement  in  results,  step  by 
step,  in  exact  proportion  to  the  exactness  of  the  application 


108  ANTISEPTIC    SUKGERY. 

of  the  antisej)tic  method.  A  mere  glance  at  the  figures  is 
enough  to  show  that  deaths  became  very  rare. 

One  hundred  cases  of  resection  are  recorded  —  shoulder, 
elbow,  wrist,  hip,  knee,  ankle, — and  two  thirds  are  of  the 
hip  and  knee. 

The  total  mortality  is  thirty-three,  that  is,  thirty-three  per 
cent. 

But  although  the  author  early  brought  the  method  into 
Denmark,  his  cases  at  first  were  treated  without  the  Lister 
dressing  or  with  a  very  imperfect  dressing,  and  here  are  the 
figures  which  they  give  :  — 

Before  1873,  fifteen  resections  with  nine  deaths  —  sixty 
per  cent,  of  mortality. 

Then  the  method  began  to  make  its  beneficence  felt,  and 
the  sum  total  before  1877  was  seventy-six  resections,  with 
thirty- two  deaths  —  a  mortality  of  forty- two  per  cent. 

After  1876  the  method  was  much  more  rigorously  applied, 
and  since  1877  thirty-four  cases,  the  greater  part  of  which 
were  large  resections  (fifteen  of  the  hip  and  twelve  of  the 
knee),  gave  only  five  deaths  —  a  mortality  of  but  seventeen 
per  cent. 

"  In  short,"  says  Saxtorph,  "  I  have  made  great  progress. 
Since  1877  I  have  constructed  a  spray-producer  which  ena- 
bles me  to  be  more  rigorous,  more  exact ;  and  since  then  I 
have  made  twenty-four  large  resections  of  joints,  almost  all 
of  the  knee  or  elbow,  and  I  have  lost  only  one  patient,  and 
that  one  by  tetanus,  which  gives  but  a  trifle  more  than  four 
per  cent,  of  deaths,  that  is  to  say,  about  a  fourteenth  part  of 
the  mortality  of  the  first  years." 

As  regards  the  patients  who  recover,  the  results  are  incom- 
parably superior,  the  functions  of  their  limbs  being  much 
more  surely  restored  and  the  absence  of  complications  re- 
markable. 


THE   HOSPITAL   AT   HALLE.  109 

With  such  results,  one  can  easily  understand  that  Saxtorph 
writes  me  as  follows  :  — 

"  There  is  nobody,  I  think,  in  Denmark  who  does  not  use 
the  Lister  dressing  in  his  operations.  As  for  me,  I  would 
give  up  the  practice  of  surgery,  if  I  could  no  longer  operate 
antiseptically." 

The  most  curious  of  all  the  personal  statistics  are  those  of 
Volkmann,  of  Halle,  whose  surgery  passed  from  the  most 
wretched  results  of  hospitalism  which  can  be  imagined  to  the 
most  perfect  security  that  one  has  a  right  to  wish  for. 

He  had  a  deplorable  induction,  into  a  hospital  manifestly 
infected.  At  the  time  when  he  began  to  employ  the  method, 
Volkmann,  in  utter  despair  of  their  sanitary  state,  was  on  the 
point  of  demanding  the  closure  of  his  wards.  It  would  seem 
that  their  aspect  was  not  enchanting  if  we  may  believe  the 
description  of  Dr.  Schuppert,  of  New  Orleans,  who  made 
very  careful  observations  of  the  antiseptic  method  throughout 
Germany.     He  says  :  — 

"  It  is  an  old,  miserable  building,  tumbling  into  ruins, 
situated  in  the  midst  of  a  dense  population,  surrounded  by 
narrow,  dark,  and  filthy  streets.  This  hospital,  if  such  it  may 
be  called,  has  no  other  means  of  ventilation  than  that  by 
infrequent  and  narrow  windows."  —  i\r.  0.  Medical  and  Sur- 
gical Journal^  March,  1876. 

The  results  were  quite  in  harmony  with  the  appearance  of 
the  hospital ;  purulent  infection  and  all  the  complications  of 
wounds  raged  with  a  violence  previously  unheard  of,  and,  to 
cite  only  one  class  of  wounds  particularly,  the  author  reports 
that  in  1872-73  he  attempted  to  save  sixteen  cases  of  com- 
pound fracture,  and  twelve  of  them  rapidly  succumbed  to 
pyaemia. 

In  1873,  Volkmann  in  despair  made  a  trial  of  the  Lister 
dressing  in  all  its  strictness,  and  from  that  time  to  1877,  he 


110  ANTISEPTIC    SURGERY. 

employed  conservative  treatment  in  seventy-five  complicated 
fractures  in  seventy-three  patients,  without  a  case  of  death. 
And  all  his  surgery  abruptly  assumed  an  aspect  of  which 
some  idea  may  be  obtained  from  the  brief  report  which  he 
made  to  the  Congress  of  German  Surgeons,  in  April,  1877, 
the  essential  points  of  which  are  subjoined. 


Operations  performed  in  the  Clinic  at  Halle  from  the  1st  of  3farch,  1874,  to 
the  1st  of  March,  1877.  Ten  thousand  cases,  of  which  one  thousand 
loere  large  operations  or  grave  injuries. 

Amputations  and  Disarticulations. 

Simple   Cases. 

Disarticulation  of  shoulder,  four.  One  death  after  four 
hours. 

Amputation  of  arm,  fourteen.     No  death. 

Amputation  of  fore-arm,  twenty-three.     No  death. 

Disarticulation  of  wrist,  three.     No  death. 

Disarticulation  of  thigh,  two.     One  death  after  four  hours. 

Amputation  of  thigh,  forty-two.  One  death  after  twenty- 
four  hours. 

Amputation  of  leg,  twenty-five.    One  death  from  erysipelas. 

Partial  amputation  of  foot,  forty-two.     No  death. 

Complicated  Cases. 

Double  amputation,  nine.  Two  deaths,  both  patients  hav- 
ing suffered  amputation  of  both  thighs. 

Serious  multiple  lesions,  six.  Six  deaths  ;  traumatism  with 
or  without  operation  ;  death  in  a  few  hours. 

Operations  in  the  course  of  septicaemia,  fifteen.  Eight 
deaths. 


volkmann's  results.  Ill 

Deaths  from  intercurrent  maladies  :  — 

A  man  of  sixty,  whose  thigh  was  amputated,  died  of  de- 
lirium tremens. 

A  tuberculous  girl  of  sixteen  died  of  pneumonia. 

A  woman  of  twenty-four  had  the  humerus  amputated  for 
phlegmon.  Abortion  followed,  and  she  died  of  puerperal 
fever. 

In  these  cases,  cicatrization  was  almost  complete  at  death. 

The  total  of  the  large  operations  was  one  hundred  and 
seventy-two,  with  twenty-three  deaths  — a  little  more  than 
thirteen  per  cent. 

Resections. 
Uncomplicated  Cases. 

Shoulder,  seven  ;   elbow,  two  ;  wrist,  two.     All  cured. 

Hip,  forty-eight.  Four  deaths,  two  of  them  after  three 
months,  the  others  in  children  aged  nine  months  and  two  and 
a  half  years  respectively. 

Knee,  twenty-one.    One  death  from  tuberculous  meningitis. 

Tibio-tarsal  articulation,  five.     No  death. 

Complicated  Cases. 

Four  in  patients  already  suffering  from  septicemia  or 
pyaemia.     Four  deaths. 

Resections  in  the  continuity  of  limbs  :  for  false  joint,  nine  ; 
for  vicious  callus,  one.     No  death. 

Osteotomy  ;  fifty  operations  on  thirty-eight  patients.     One    * 
death  from  hemorrhage  in  a  bleeder. 

Operations  on  the  breast:  one  hundred  and  nineteen  on 
one  hundred  and  ten  patients.  Six  deaths  :  two  of  erysipelas, 
one  arising  from  neglected  dressing,  the  other  from  an  eschar 


112  ANTISEPTIC    SUEGERY. 

on  the  sacrum ;  one  of  shock ;  two  of  exhaustion  ;  one  of 
malignant  pustule,  communicated  b}^  the  catgut. 

Incisions  of  hydroceles,  forty-five  cases.     No  accidents. 

Complicated  fractures  treated  conservatively,  seventy-five 
in  seventy-three  patients.     No  death. 

Secondary  amputations :  thigh,  one  ;  knee,  four  ;  leg,  forty- 
two  ;  arm,  six  ;  elbow,  five ;  fore-arm,  fifteen.     No  death. 

During  this  period  of  three  years,  there  was  not  a  case  of 
purulent  infection  excepting  such  as  existed  on  admission  to 
the  hospital. 

There  were  three  or  four  cases  of  erysipelas  in  patients 
treated  antiseptically,  and  some  others  in  the  non-antiseptic. 

From  these  statistics  it  is  worth  while  to  select  a  few  which 
are  really  remarkable  and  very  important.  For  example, 
Volkmann  reports  resections  of  the  shoulder  cured  in  fifteen 
days  ;  a  resection  of  the  elbow  healed  without  pus  in  nine- 
teen days  ;  one  of  the  hip  on  the  ninth  day  without  a  drop  of 
pus  ;  and  one  of  the  knee  in  a  child  of  nine  years,  having 
caries  with  luxation  and  a  large  abscess,  uniting  without  sup- 
puration. A  month  after  the  operation,  the  wound  being 
completely  healed,  the  child  was  walking  about  without  a 
stick,  his  limb  being  supported  by  a  splint.  The  bone  tissue 
was  so  soft  that  it  was  cut  with  a  knife. 

A  man  of  forty-five  years,  who  had  suffered  disarticulation 
of  the  thigh  on  account  of  a  myxolipoma  sixty  centimeters  in 
diameter,  had  his  wound  completely  healed  in  ten  days,  ex- 
cepting the  track  of  the  tubes. 

A  woman,  aged  eighty-four,  recovered  from  amputation  of 
the  thigh,  necessitated  by  an  injury. 

A  patient,  from  whose  back  a  fibro-sarcoma  measuring 
twenty-five  centimeters  in  diameter  was  removed,  left  the 
hospital  on  the  fourteenth  day. 

I  hardly  know  where  to  end  my  recital  of  these  curious 


UNIVERSAL   SUCCESS.  113 

examples  of  rapid  repair,  but  I  must  add  the  remarkable  ex- 
perience which  Dr.  Auguste  Reverdin  reports  to  me,  of  a 
patient  both  of  whose  feet  were  amputated  by  the  Pirogoff 
method,  six  weeks  intervening  between  the  operations.  The 
first  was  completely  healed  in  fifteen  days,  the  second  in 
seventeen. 

In  describing  the  antiseptic  surgery  of  Volkmann,  I  should 
have  said  that  his  practice  does  not  differ  from  that  of  Lister. 
He  is  rather  more  inclined  to  employ  compression  above  the 
dressing.  In  places  where  it  is  difficult  to  accurately  apply 
the  dressing,  he  often  completes  it  with  salicylic  wadding. 

I  may  add  that  Volkmann,  to  a  much  greater  extent  than 
Lister,  employs  irrigation  with  the  strong  solution,  which  he 
pours  out  from  watering-pots  lavishly  in  every  direction  in 
his  amphitheatre. 

At  the  present  time  the  surgeons  who  have  adopted  the 
method  are  innumerable  ;  but  we  must  make  mention  of  our 
colleague,  Jules  Bceckel,  of  Strasburg,  and  Nussbaum,  of 
Munich  ;  and  we  could  give  the  names  of  English,  German, 
Danish,  Dutch,  Austrian,  Swiss,  Italian,  Russian,  and  French 
surgeons  who  have  successfully  practised  Listerism. 

I  have  already  said  what  my  results  have  been  with  anti- 
septic surgery  in  the  hospitals  of  Paris ;  and  yet  I  desire  to 
repeat  that  I  have  made  a  great  many  capital  operations  with- 
out encountering  a  wound-complication.  The  only  patients 
I  have  lost  were  those  who  could  not  withstand  traumatism, 
and  some  of  these  survived  only  a  few  hours. 

I  could  quote  Guyon,  the  member  of  the  Surgical  Society 
who  has  most  rigorously  applied  the  Lister  dressing,  and 
whose  first  attempts  gave  the  following  results :  twenty-one 
capital  operations,  twenty-one  recoveries ;  seven  hernioto- 
mies, five  recoveries. 

To  show  that  every  one  can  easily  obtain  equally  good  re- 


114  ANTISEPTIC   SURGERY. 

suits,  I  may  be  allowed  to  mention  the  first  experience  of  my 
associate,  Dr.  Gilbrin,  surgeon  of  the  hospital  at  Metz.  In 
1874  he  was  in  utter  despair  at  the  results  of  his  surgery  in 
the  hospital,  having  exhausted  almost  all  known  means  to 
prevent  the  accidents  of  wounds.  He  could  not  operate  upon 
a  patient  without  having  hospital  gangrene  set  in.  Having 
read  in  the  Journal  of  Practical  Medicine  and  Surgery  a 
review  of  the  thesis  of  Zayas  Bazan,  he  procured  it,  and 
resolved  to  devote  himself  to  the  strict  execution  of  the  pre- 
scriptions of  antiseptic  surgery.  He  began  on  the  1st  of 
January,  1875,  with  this  very  concise  guide.  From  that  day 
on  there  were  no  accidents,  not  another  case  of  hospital 
gangrene  occurred ;  and  yet  he  performed  operations  which, 
in  the  former  circumstances,  he  would  not  have  dared  to 
undertake.  To-day  Gilbrin  has  perfect  results,  and  is  an 
ardent  disciple  of  Lister. 

If  we  do  not  yet  say,  with  Socin,  of  Bale,  that  every  sub- 
ject of  amputation  who  dies  of  purulent  infection  or  erysip- 
elas is  a  victim  of  ignorance,  lack  of  skill,  or  neglect  of  the 
surgeon,  at  least  we  think  this  is  so  near  the  truth  that  we 
look  upon  it  simply  as  a  vivacious  expression  of  his  idea  of 
the  power  which  the  Lister  method  has  given  to  surgery. 


CHAPTER   XIII. 

Particular  Operations  AND  Dressings.  —  Practice  and  Results. 
—  Immediate  Union.  —  Plastic  Operations.  —  Extirpation  of 
Tumors   op  the  Soft  Parts. 

In  describing  certain  great  operations,  and  the  dressings 
adapted  to  them,  I  shall  point  out  the  particular  conditions 
of  each  case  and  the  results  obtainable. 

Immediate  union.     Plastic  operations. 

Many  surgeons  with  good  reason  say  that  immediate  or 
rapid  union  is  one  of  the  greatest  advantages  of  the  method. 
Not  only  is  this  assured  in  all  plastic  operations,  where  we 
formerly  endeavored  to  obtain  it,  but  in  all  operations,  what- 
ever may  be  the  nature  or  the  depth  of  the  wound,  if  its  walls 
can  be  brought  into  apposition. 

In  four  years  I  have  seen  a  failure  of  union  not  more  than 
two  or  three  times.  The  wound  always  unites,  if  it  is  anti- 
septically  clean  and  its  walls  are  held  in  contact  with  suffi- 
cient firmness.  This  healing  is  surprisingly  easy,  not  failing 
on  account  of  the  presence  of  small  blood-clots,  or  the  imper- 
fect suture  of  the  parts. 

The  deep  suture,  which  some  have  considered  the  principal 
feature  of  the  method,  is  really  an  accessory  measure,  and,  if 
it  is  not  narrowly  watched,  it  is  more  likely  to  hinder  than 
to  favor  healing,  by  inducing  the  formation  of  purulent 
sinuses. 

It  is,  on  the  other  hand,  of  the  first  importance  to  provide 


116  ANTISEPTIC    SUEGERY. 

for  drainage,  and  this  all  the  more  because  parts  which  have 
been  bathed  with  carbolic  acid  exude  a  large  amount  of 
serous  fluid. 

But,  these  conditions  being  fulfilled  and  antiseptic  protec- 
tion assured,  union  will  take  place  not  only  after  all  great 
surgical  operations,  but  also  after  those  interferences  which 
formerly  we  hardly  dreamed  of  having  it  follow,  such  as  the 
opening  of  large  abscesses  and  articulations. 

I  have  had  union  in  all  regions,  even  in  those  where 
attempts  at  healing  are  often  vain,  such  as  the  integuments 
of  the  skull,  after  removal  of  wens  and  lipomata,  and  after 
contused  wounds ;  in  the  face,  after  operations  for  the  remo- 
val of  sequestra.  I  have  always  obtained  it  after  operations 
involving  the  peritoneum,  as  in  strangulated  hernia,  after 
evacuating  large  abscesses,  and  after  opening  joints. 

It  is  clear  that,  to  favor  this  process,  it  is  wise  to  retrench 
the  tendons  and  aponeuroses  which  protude  in  the  depths  of 
the  wound,  and  to  so  arrange  the  various  parts  that  apposi- 
tion shall  be  perfect.  It  is  almost  a  matter  of  indifference 
what  materials  are  employed  to  effect  coaptation ;  metal,  car- 
bolized  silk,  and  catgut,  all  in  turn  have  given  good  results. 

In  plastic  operations  drainage  may  be  entirely  useless,  or 
may  be  accomplished  with  a  bit  of  protective.  It  is  well  to 
cover  the  united  parts  with  fine  linen  saturated  with  boracic 
ointment,  and  cover  it  with  boracic  dressing.  If  the  flaps 
are  large,  it  is  an  excellent  plan  to  wash  them  with  carbolic 
acid ;  if  they  are  small,  the  boracic  solution  may  be  sufficient. 

Removal  of  tumors  from  the  soft  parts. 

All  the  tumors  to  which  a  common  treatment  is  applicable 
may  be  described  together  :  superficial  and  deep  lipomata, 
tumors  of   the   breast,  tumors    of  the   parotid,  degenerated 


REMOVAL   OF   TUMORS.  117 

ganglions,  etc.  In  all  these  cases  I  have  tried  the  antiseptic 
method,  and  I  will  give  the  general  rules,  which  should  be 
followed. 

The  incisions,  whether  single  or  multiple,  should  expose 
the  tumors  in  their  entire  extent.  A  long  incision  is  not  a 
disadvantage,  as  the  scar  is  linear,  and  it  gives  an  opportunity 
for  radical  extirpation,  and  prompt  and  certain  arrest  of 
hemorrhage. 

All  tissues  which  will  prevent  the  healing  process,  such  as 
fibrous  envelops  and  cyst  walls,  should  be  carefully  removed. 
The  cavitj'-  produced  is  washed  out  with  strong  carbolized 
water,  after  bleeding  has  been  stopped.  I  have  often  done 
it  with  an  eight  per  cent,  solution  of  chloride  of  zinc,  with 
very  good  results ;  but  a  livelier  reaction  and  greater  pain 
are  liable  to  follow. 

If  the  soft  parts  which  are  to  be  united  are  very  far  apart, 
one,  two,  or  three  deep  stitches  may  be  taken,  compression  of 
the  drainage  tubes  always  being  scrupulously  avoided.  On 
the  following  days  a  strict  watch  should  be  kept  on  them, 
that  they  may  be  removed  as  soon  as  they  have  fulfilled  their 
mission. 

There  is  danger  that  the  superficial  stitches  may  be  drawn 
too  tightly.  Silk  or  catgut  may  be  used,  but  I  prefer  silver, 
though  sometimes  employing  catgut.  The  last  is  especially 
applicable  to  wounds  of  small  extent.  This  thread,  which 
swells  by  absorption  of  moisture,  must  be  carefully  watched. 

Drainage  is  very  important,  and,  if  the  cavity  is  of  great 
size,  it  is  wise  to  insert  several  tubes,  and  remove  them  as 
soon  as  their  work  is  done. 

Compression  with  carbolized  sponges  placed  in  the  dress- 
ing above  the  protective  is  here  a  great  assistance.  They  are 
of  advantage  by  absorbing  the  discharge  and  favoring  apposi- 
tion by  the  compression  which  they  exert. 


118  ANTISEPTIC    SPRGERY. 

I  have  extirpated  a  large  number  of  different  kinds  of 
tumors.  I  may  mention  the  ablation  of  a  mass  of  enlarged 
lymphatics  from  the  axilla  of  a  little  girl  of  fifteen.  The 
glands  extended  as  high  as  the  clavicle  ;  and  yet,  after  the 
lips  of  the  wound  were  sutured,  and  the  dressing  carefully 
applied  with  sponge  compression,  complete  healing  of  this 
immense  cavity  took  place  in  two  weeks.  I  have  got  com- 
plete and  rapid  healing  after  the  removal  of  an  enormous 
lipoma  of  the  nape,  and  also  after  ablation  of  mammary 
tumors. 

In  all  cases  of  tumor,  it  is  of  the  utmost  importance  to 
obtain  very  rapid  union,  for  without  it  healing  is  indefinitely 
delayed ;  we  must  not  be  afraid  to  bring  the  lips  of  the  wound 
together  even  forcibly,  if  we  watch  the  sutures  and  are  ready 
to  loosen  them  at  the  least  sign  of  inflammation.  In  these 
cases,  the  wound  should  be  dressed  daily. 

In  the  treatment  of  tumors,  the  salicylic  wadding  or  lint 
is  often  useful  to  make  compression  upon  the  remaining 
cavity. 


CHAPTER   XIV. 

Compound    Fractures.  —  Purification.  —  Immobilization.  —  Gun- 
shot Wounds  in  Military  Surgery. 

The  antiseptic  treatment  of  compound  fractures  and  gun- 
shot wounds  gives  marvellous  results ;  but  these  depend 
mostly  upon  the  pains  bestowed  upon  the  first  dressing.  As 
the  air  has  penetrated  to  a  greater  or  less  extent,  we  should 
not  concern  ourselves  as  particularly  with  the  application  of 
the  spray  as  with  the  perfect  purification  of  the  wound  and 
all  its  sinuosities.  At  the  time  of  the  subsequent  dressings, 
the  wound  naturally  being  supposed  to  be  aseptic,  the  spray 
is  of  the  utmost  importance. 

The  wound  and  the  surrounding  parts  having  been 
thoroughly  washed  in  the  one-to-twenty  solution,  we  care- 
fully examine  it  and  find  out  whether  it  will  be  possible  to 
reach  with  injections  to  the  bottom  of  its  cavities.  If  these 
are  large,  with  narrow  orifices,  we  need  not  hesitate  to  en- 
large the  openings  sufficiently  to  insure  purification.  We 
do  this  the  more  readily  because,  after  the  washing  is  com- 
pleted, it  is  easy  enough  to  take  a  few  stitches  and  close  the 
wound  of  the  bistoury.  It  is  also  well  to  secure  the  detached 
flaps  with  sutures. 

The  washing  of  the  cavities  should  be  scrupulously  made 
with  strong  carbolized  water,  and  for  this  purpose  a  good 
rubber  bulb  charged  with  the  fluid  is  very  convenient. 

If  the  wound-cavity  is  not  uncovered,  it  is  very  convenient 
to  introduce  a  soft  tube,  and  make  the  injection  through  it ; 
in  this  way  the  distant  crevices  can  be  reached  and  the  return 


120  ANTISEPTIC    SURGERY. 

of  the  fluid  assured.  This  last  point  is  exceedingly  im- 
portant, for  we  must  not  forget  that  there  are  loosened  flaps 
and  denuded  bone,  and  by  forcible  injections  the  injuries  of 
the  soft  parts  may  be  aggravated,  and  hemorrhage  is  provoked. 

In  cases  where  the  fracture  dates  far  enough  back  to  have 
become  poisoned,  or  where  it  has  been  contaminated  with 
impurities  at  the  time  of  injury,  it  may  perhaps  be  well  to 
use  a  twenty-per-cent.  alcoholic  solution  of  carbolic  acid  for 
the  washings  and  injections.  But  it  should  be  borne  in  mind 
that  this  solution  is  powerfully  caustic.  We  should  be  mod- 
erate in  the  use  of  it,  not  slopping  it  upon  the  skin,  which  it 
will  burn,  and  not  forcing  it  violently  into  the  tissues,  lest  it 
excite  active  inflammation. 

The  aqueous  solution  gives  the  blood  a  chocolate-brown 
color ;  the  alcoholic  imparts  a  gray  hue  to  the  blood  and 
uncovered  muscles  which  shrivel  at  its  touch,  and  the  burn- 
ing sensation  is  intense ;  whereas,  in  the  first  case,  the  patient 
has  little  suffering. 

If  the  fracture  is  of  several  days'  standing,  and  suppura- 
tion has  set  in,  we  must  not  hesitate  to  freshen  the  cavity 
with  the  curette  and  purify  it  with  chloride  of  zinc.  In  this 
case,  the  greatest  circumspection  should  be  observed  in  the 
injection,  and,  as  the  solution  is  very  caustic,  its  complete 
return  should  be  insured.  I  do  not  much  favor  its  employ- 
ment in  the  beginning  for  a  fresh  fracture.  It  has,  indeed, 
been  recommended  ;  but  it  seems  to  me  to  be,  at  least,  use- 
less in  such  cases. 

In  compound  fractures  the  care  bestowed  upon  the  drain- 
age should  be  in  proportion  to  the  irregularity  of  the  cavity. 
It  should  be  aided  by  gentle  compression  with  sponge  or 
gauze.  At  each  dressing,  one  can  make  sure  that  there  is  no 
retention  of  fluid,  by  making  light  pressure  and  thus  empty- 
ing the  culs-de-sac  and  ensuring  rapid  repair. 


PLASTER   BANDAGE   USEFUL.  121 

It  is  useless  to  insert  the  drains  as  far  as  the  centre  of  the 
fracture.  It  suffices  to  place  them  below  and  along  side  of 
the  bones. 

We  should  bear  in  mind  that  it  is  generally  of  no  use  to 
repeat  the  injections,  the  dressing  having  been  once  well 
applied,  and  that,  on  the  contrary,  this  proceeding  disturbs 
repair,  prolongs  the  cure,  and  even  provokes  suppuration. 

Ordinarily  the  dressing  is  made  with  quite  thick  layers  of 
gauze,  because  its  form  is  necessarily  irregular,  and  because 
there  is  often  abundant  discharge. 

Of  all  solid  appliances  the  plaster  bandage  is  the  most 
easily  combined  with  the  antiseptic  dressing.  If  the  open- 
ings in  the  apparatus  are  not  very  large,  it  is  well  to  line 
their  edges  with  antiseptic  gauze,  under  which  we  slip  the 
impermeable.     The  dressing  must  be  frequently  renewed. 

Finally,  in  the  dressing  of  compound  fractures,  the  sali- 
cylic wadding  or  jute  answers  a  good  purpose  in  filling  up 
empty  places  and  completing  the  dressing. 

In  the  cases  where  I  have  feared  that  antisepsis  was  not 
well  assured,  on  account  of  the  necessary  narrowness  of  the 
openings  of  the  apparatus,  I  have  enveloped  the  limb  and 
the  wounded  region  above  the  dressing  with  a  kind  of  ban- 
dage of  Scultetus,  formed  of  large  bands  of  carbolized  gauze. 
Another  piece  of  impermeable  placed  above  assured  me  that 
the  fluids  which  ran  from  the  dressing,  being  received  by  the 
carbolized  bands,  could  not  putrefy.  In  the  first  days  of 
treatment  one  cannot  take  too  many  precautions,  when  the 
discharge  of  fluids  is  abundant. 

The  dressing  is  evidently  as  favorable  to  the  repair  of  bone 
as  to  that  of  the  soft  parts,  and  one  is  surprised  to  see  that 
the  necessity  for  immobilization  is  only  relative.  Obviously 
the  bony  fragments  should  not  be  disturbed  by  large  move- 
ments.    But  while  authors  attach  great  importance  to  the 


122  ANTISEPTIC    STJEGEEY. 

immobilization  of  a  compound  fracture,  we  find  here  that 
with  small  movements  and  an  apparatus  moderately  immo- 
bilizing, consolidation  goes  on  well,  and  no  inflammatory 
complications  result.  This  fact  is  of  essential  value  in  the 
treatment  of  certain  fractures.  I  have  even  acquired  the 
habit,  in  cases  of  fractures  into  or  near  joints,  of  not  immo- 
bilizing completely,  in  order  that  I  may  try  to  preserve  the 
articular  movements. 

In  1877,  at  the  Hospital  of  Lariboisi^re,  I  treated  in  this 
manner  a  man  who  had  a  fracture  just  above  the  right  elbow, 
with  considerable  crushing  of  the  integuments,  from  being 
run  over  by  a  carriage.  It  was  put  up  in  a  gutter-like  splint, 
and,  every  time  it  was  dressed,  movements  were  made  in  the 
joint.  The  healing  was  very  rapid,  the  callus  was  perfectly 
solid,  and  he  had  sufficiently  extended  movements  of  the 
elbow  when  he  was  discharged.  I  attach  importance  to  this 
fact,  because  I  am  one  of  those  who  believe  in  the  influence 
of  the  immobilization  upon  rigidity  of  joints. 

The  progress  of  compound  fractures  is  remarkable.  At 
first,  there  is  an  abundant  discharge  of  blackish  serum  ;  in 
the  following  days  the  serum  becomes  turbid ;  sometimes  it 
approaches  the  appearance  of  pus,  without  becoming  creamy; 
then,  as  cicatrization  goes  on,  there  is  no  longer  any  discharge 
from  the  wound  excepting  a  slightly  viscid  serum,  strongly 
resembling  synovia  ;  finally  the  discharge  dries  up  and  the 
wound  is  closed.  If  the  bone  is  extensively  shattered,  this 
discharge  lasts  some  time  ;  it  is  seen  in  bad  fractures  of  the 
leg.  But  if  the  break  is  not  extensive,  reunion  is  rapid  and 
is  accomplished  absolutely  by  first  intention. 

This  very  happy  progress  of  fractures  is  observed  in  shafts 
of  large  bones,  in  small  bones,  and  fractures  into  joints  with 
the  same  regularity.  In  1877,  I  could  show  at  one  time  in 
the  service  that  I  directed  at  the  Hospital  of  Lariboisi^re,  a 


ANTISEPSIS   IN   WAR.  123 

fracture  of  the  lower  end  of  the  humerus,  opening  into  the 
joint,  multiple  fractures  of  metacarpal  bones  and  phalanges 
in  a  crushed  hand,  a  fracture  of  both  malleoli  communicating 
with  the  articulation,  and  a  fracture  of  the  femur  extending 
into  the  knee-joint.  All  these  patients  simultaneously  re-, 
covered  without  suppuration  and  with  the  preservation  of 
the  movements  of  the  injured  joints.  The  cases  in  which 
suppuration  continues  are  exceptional,  and,  in  the  greater 
number,  our  failure  is  to  be  attributed  to  the  impossibility  of 
sufficiently  purifying  the  cavity. 

The  most  formidable  compound  fractures  are  seen  in  mili- 
tary practice,  and  our  chief  concern  is  to  keep  infection  from 
the  wounds  before  they  can  be  treated  in  a  thoroughly  anti- 
septic manner.  Nassbaum,  who  says  that  "  the  fate  of  a 
wounded  man  depends  almost  entirely  upon  the  physician 
who  treats  the  wound  during  the  first  hours,"  is  of  opinion, 
like  the  greater  part  of  German  surgeons,  that  the  best  thing 
to  do  is  to  furnish  the  soldier  with  a  tampon  of  salicylic 
wadding  or  jute,  tied  up  in  a  piece  of  salicylic  gauze.  The 
tampon  being  immediately  applied  to  the  wound  protects  it, 
and  the  salicylic  acid,  dissolving  in  the  discharged  fluids, 
prevents  infection.  The  first  immobilizing  dressing  of  the 
limb  ought  to  be  made  without  examining  the  wound,  since 
the  patient,  in  the  ambulance  or  hospital,  can  have  the  bene- 
fit of  a  perfectly  antiseptic  method,  whicli  is  impossible  upon 
the  battle-field ;  and  a  wound  which  has  not  been  opened  in 
any  way  will  not  receive  any  additional  poison. 


CHAPTER  XV. 

Osteotomy.  —  Rachitic  CuRVATUREa  and  Genu  Valgum. — Frac- 
tures  OF  Joints.  —  Resection  in  False  Joints. 

An  operation  which  consists  in  deliberatelv  making  a  com- 
pound fracture,  and  that,  too,  generally  merely  for  the  correc- 
tion of  a  deformity,  was  incapable  of  full  development  until 
one  could  be  assured  that  this  wound,  if  sufficiently  protected, 
would  expose  the  patient  to  no  greater  danger  than  would  a 
wound  of  the  soft  parts  in  like  circumstances.  Nowadays  we 
do  these  operations  fearlessly,  even  if  they  open  more  or  less 
extensively  into  joints.  In  the  beginning  of  his  antiseptic 
practice,  Lister  set  the  example,  since  often  followed,  in  the 
case  of  a  man  who  had  outward  luxation  of  the  foot.  He  cut 
down  upon  the  vicious  callus,  laid  the  articulation  freely  open, 
straightened  the  foot,  and  obtained  perfect  healing  without 
suppuration. 

Some  years  after  he  made  an  operation  of  the  same  kind 
for  a  vicious  callus  of  the  elbow  which  prevented  extension 
of  the  limb.  He  opened  the  joint,  excised  the  exuberant  ma- 
terial, and  the  patient  recovered  without  any  drawback,  and 
regained  all  the  movements  of  the  member. 

Resection  of  a  vicious  callus  may  be  easily  made,  and  a  few 
days  are  sufficient  to  insure  healing.  Dr.  P^rier  recently 
showed  the  Surgical  Society  a  young  man  on  whom  he  had 
operated  for  a  bad  callus  of  the  clavicle,  which  threatened  to 
perforate  the  skin.  He  excised  all  the  prominent  portion, 
and  in  a  few  days  the  healing  process  was  completed,  union 
having  been  obtained  by  first  intention. 


CORRECTION   OF   BONY   CURVATURES.  125 

Section,  with  or  without  excision  of  a  wedge-shaped 
fragment  of  bone,  has  been  practised  for  the  purpose  of 
straightening  rachitic  curvatures  of  the  lower  limbs,  to  correct 
genu  valgum,  and  to  relieve  ankylosis  of  a  neighboring  artic- 
ulation. 

In  genu  valgum,  the  operation  is  done  by  making  a  sec- 
tion of  the  articular  surfaces  in  order  to  displace  a  condyle, 
or  by  removing  a  portion  of  bone  to  straighten  the  limb,  the 
joint  being  opened  or  not,  as  the  case  may  be.  Although 
these  operations  were  made  prior  to  the  introduction  of  the 
antiseptic  method,  they  were  not  really  justifiable. 

The  directions,  which  a  surgeon  who  does  these  operations 
antiseptically  should  observe,  are  as  follows  :  — 

Instead  of  striving,  as  formerly,  to  make  the  incisions  as 
small  as  possible,  so  that  the  operation  may  be  more  or  less 
subcutaneous,  we  make  large  openings,  which  allow  us  to 
freely  uncover  the  bone,  and  make  the  section  of  it  in  the 
best  possible  conditions. 

Formerly,  the  saw  was  regarded  as  much  more  dangerous 
than  other  instruments,  but  we  do  not  now  consider  it  an 
important  factor  in  the  production  of  septic  complications. 
However,  to  insure  perfect  results,  it  is  indispensable  that 
all  particles  of  bone  should  be  washed  out  of  the  wound. 

Finally,  we  must  make  sure  that  the  drains  do  not  inter- 
pose between  the  osseous  surfaces  which  ought  to  be  in  con- 
tact, for  this  little  accident  easily  happens  and  is  a  source  of 
great  irritation. 

Besides  these  directions,  there  is  nothing  special  to  add. 
Extension,  traction,  movements,  or  fixation  will  be  employed 
in  all  these  operations,  as  if  the  antiseptic  method  were  not 
"used. 

In  making  operations  of  this  kind,  it  is  well  to  remember 
a   case   reported  by  Lister  in  the  British  Medical  Journal, 


126  ANTISEPTIC   SURGEKY. 

in  1877.  It  was  a  recent  fracture  of  the  patella,  with  con- 
siderable separation  of  the  fragments,  and  the  operation  con- 
sisted in  opening  the  joint,  emptying  it,  carefully  cleansing 
the  pieces,  suturing  them  together  with  silver  wire,  and  drain- 
ing the  articulation  with  a  bundle  of  horsehair.  In  three 
weeks  cicatrization  was  complete,  but  he  waited  until  consoli- 
dation was  perfect  before  he  withdrew  the  wire.  He  has 
repeated  this  operation  successfully  on  old  fractures. 


Resection  for  the  relief  of  false  joint,  also,  has  become  an 
operation  free  from  gravity,  and,  with  the  addition  of  the 
antiseptic  protection,  may  be  successfully  performed  in  the 
same  manner  as  formerly.  I  saw  a  beautiful  example  of  this 
—  a  pseudarthrosis  of  the  femur  —  in  the  service  of  Lister,  in 
1875.  But  we  must  not  lose  sight  of  the  fact  that  the  anti- 
septic method  reduces  to  their  minimum  the  phenomena  of 
irritation  in  a  wound.  Now,  it  happens  that,  while  the 
osseous  extremities  need  to  be  excited  in  order  to  form  the 
callus,  the  reaction  is  insufficient,  and  the  wounds  heal  rapidly 
without  our  obtaining  the  desired  result. 

Three  years  ago  I  operated  upon  a  man  for  false  joint  in 
the  right  humerus.  In  spite  of  very  extensive  resection  of 
the  fragments,  in  spite  of  the  pulling  and  bruising  of  the  soft 
parts  during  the  operation,  at  the  end  of  eighteen  days  cicatri- 
zation was  perfect,  without  the  patient's  having  had  a  touch 
of  fever.  But  the  mobility  was  not  relieved  ;  in  spite  of 
sufficient  juxtaposition  of  the  parts,  no  callus  was  formed. 

Other  surgeons  have  had  the  same  experience,  and,  follow- 
ing Volkmann,  we  have  established  the  following  principle. 
During  the  first  days  we  dress  antiseptically,  until  danger  of 
the  more  serious  complications  is  past.     Then,  while  there 


RELIEF   OF   FALSE   JOINT.  127 

remains  only  a  moderate  passage  between  the  ends  of  the 
pieces,  we  abandon  the  antiseptic  method,  and  let  the  infected 
air  enter  the  cavity  sufficiently  to  excite  osseous  secretion. 

Most  operators,  however,  insist  upon  the  necessity  of  fast- 
ening the  fragments,  either  by  metallic  ^suture,  a  peg  of  ivory, 
iron  nails  plated  with  tin,  as  recommended  by  Nussbaum,  or 
a  silver  screw,  as  Langenbeck  advises.  When  the  fragments 
are  united  with  these  large  and  irritant  bodies,  a  sufficient 
formation  of  callus  is  provoked  by  their  presence,  and  we  can 
dispense  with  the  introduction  of  septic  air,  which  is  always 
a  disturbing  procedure. 


CHAPTER  XVI. 

Amputations  and  Disarticulations. 

The  greater  part  of  the  dressings  which  are  at  all  comparable 
to  the  Listerian  were  only  intended  for  amputations  at  first, 
as,  for  example,  the  Bordeaux  and  the  wadded  dressings.  As 
we  have  already  seen,  the  Lister  method  in  amputations  is 
only  a  particular  application  conforming  to  general  rules. 
These  rules  have  produced  so  profound  a  modification  in  the 
phenomena  of  repair  that  they  have  largely  changed  the  con- 
ditions of  amputations.  Not  only  do  the  subjects  of  amputa- 
tions recover,  but  the  ease  of  recovery  is  such  that  the  surgeon 
is  much  more  at  liberty  to  select  the  operative  procedure  in 
the  best  interests  of  prosthesis,  and  to  employ  methods  to 
which,  until  now,  there  were  objections. 

Thus,  flap  methods  are  reckoned  first,  and  the  procedures 
of  Marcellin  Duval,  which  have  been  applied  mathematically 
at  all  points  of  the  limbs  for  the  formation  of  large  flaps,  are 
in  the  foremost  rank. 

This  is  susceptible  of  easy  proof,  as  I  can  show  with  respect 
to  amputation  above  the  malleoli  with  a  large  posterior  flap, 
in  a  private  patient  at  the  present  moment.  Several  times  I 
have  done  Guyon's  operation,  which,  while  it  differs  in  its 
details  from  that  of  Duval,  is  based  upon  an  analogous  prin- 
ciple to  that  which  constitutes  the  general  method  of  the 
eminent  naval  professor  ;  and  I  am  competent  to  judge  after 
what  I  have  observed  of  the  behavior  of  the  large  posterior 
flap. 


ANTISEPTIC   AMPUTATIONS. 


129 


I  was  able  to  sliow  the  Surgical  Society  the  very  remarka- 
ble results  which  I  obtained  in  a  wounded  man,  who  recov- 
ered in  twenty  days.  There  was  linear  union  of  the  flap,  the 
parts  were  perfectly  flexible,  there  was  entire  absence  of 
inflammation  about  the  bone,  and  the  patient  walked  about 
upon  the  flap  with  the  aid  of  a  very  simple  apparatus  of 
Werber's. 

In  this  amputation  I  have  recommended  and  practised 
excision  of  the  nerve  trunks,  as  has  already  been  advised  in 
amputations.  Here,  where  the  patient  has  to  walk  upon  a 
flap  in  which  there  is  a  large  nerve,  I  consider  this  step  much 
more  necessary,  and  twice  I  have  excised  the  posterior  tibial 
as  high  as  possible.  The  results  have  been  excellent,  and  I 
am  pleased  to  see  that  Guyon  has  adopted  this  step  in  his 
operation.  Soon  after,  I  operated  upon  a  man  in  disadvan- 
tageous circumstances,  and  I  observed  the  same  regularity 
of  scar  and  perfect  flexibility  of  flaps  at  the  expiration  of 
twenty-four  days.  Guyon  has  made  the  same  observations 
in  his  cases. 

So,  taking  these  cases  of  perfect,  permanent  union  of  large 
flaps  as  examples,  I  say  that  there  is  no  longer  any  objection 
to  making  them  as  Duval  proposed  ;  and  I  am  of  opinion,  also, 
that  excision  of  the  nerve  trunks  augments  the  serviceable- 
ness  of  the  stump  and  diminishes  suffering  during  treatment. 

What,  then,  are  the  rules  to  follow  in  applying  the  anti- 
septic method  to  amputations?  Choose  those  methods  of 
operating  which  make  the  application  of  sutures  easy;  en- 
deavor to  prevent  everything  whicli  can  interfere  with  union  ; 
retrench  tendons  and  aponeuroses,  and  superfluous  muscular 
tissue  in  the  flaps  ;  make  a  high  section  of  the  bones  ;i  take 

1  The  over-heating  of  the  bone,  which  is  believed  to  stand  in  a  causa- 
tive relation  to  the  necrosis  of  the  surfaces  which  occasionally  occurs, 
may  be  largely  avoided  by  pouring  weak  carbolic  solution  over  the  saw 
during  the  section. 


130  ANTISEPTIC    SURGEEY. 

pains  with  the  suture,  and,  above  all,  drain  by  one,  two,  or 
even  three  tracks. 

The  deep  suture  is  not  at  all  a  necessity  of  the  dressing, 
indeed  is  only  occasionally  called  for,  as  when  flabby  flaps 
need  to  be  held  together,  when  the  flaps  are  insufficient,  as 
happens  sometimes  in  amputations  after  traumatism,  etc.  I 
think  I  have  never  used  it  more  than  twice  in  large  amputa- 
tions. I  may  add  that  I  have  seen  a  pseudo-Lister  dressing 
in  which  union  was  completely  prevented  by  the  fault  of 
these  deep  sutures. 

Drainage  may  be  well  insured  generally  by  two  drains  at 
the  base  of  the  flap  ;  but  if  it  is  large,  a  third  may  be  neces- 
sary. The  drains  may  go  close  to  the  bone,  but  should  not 
irritate  it ;  and  it  is  well  to  shorten  them  as  soon  as  possible 
in  order  to  avoid  the  danger  of  their  remaining  in  contact 
with  it.  The  opposite  practice  was  formerly  followed  by 
those  who  used  drains  in  stumps. 

Gentle  compression  is  often  very  favorable  to  union.  I  do 
not  agree  with  Volkmann  in  thinking  it  desirable  to  make  it 
very  firm,  and  I  usually  employ  in  amputations  layers  of 
pressed  sponge  which  have  been  soaked  in  the  strong  solution 
of  carbolic  acid. 

Close  watching  of  the  sutures  and  drainage  is  more  essen- 
tial here -than  in  other  wounds.  We  must  not  remove  the 
clots,  or  worry  the  flaps,  or  make  injections  under  them  ;  but 
we  should  favor  drainage  of  fluids,  and  cut  the  stitches  as 
soon  as  they  begin  to  irritate  the  skin  or  provoke  the  forma- 
tion of  a  little  pus. 

Disarticulation  wounds  ought  to  be  treated  exactly  like 
those  of  amputation  in  the  continuity  of  limbs.  The  thro  wing- 
off  of  the  articular  cartilages  by  suppuration  is  not  a  necessity, 
as  we  find  that  these  wounds  close  like  the  others.  They 
are  not  more  dangerous  than  other  amputation  wounds,  but 


DISAETICULATIONS.  131 

they  should  be  drained  with  particular  care.  In  all  great 
amputations  there  is  need  of  providing  good  drainage ;  and 
many  surgeons,  only  half  doing  this,  have  failures  which  are 
a  decided  contrast  to  their  success  in  operations  upon  less 
extensive  surfaces. 

Great  pains  should  be  taken  with  the  spray,  which  ought 
to  envelop  all  the  parts  involved.  And  in  the  subsequent 
dressings,  too,  I  advise  especial  attention  to  this  point. 

All  the  statistics  of  experts  in  this  practice  contain  reports 
of  large  disarticulations,  even  that  of  the  thigh,  which  have 
healed  just  like  the  smaller  amputations.  One  of  the  most 
interesting  of  my  cases  occurred  in  the  person  of  a  little  girl 
of  six,  in  the  Saint  Eugenie  Hospital,  on  whom  I  performed 
disarticulation  at  the  left  shoulder.  She  had  been  run  over 
by  a  street-car,  and  the  injury  was  so  extensive  that  I  was 
obliged  to  make  my  amputation  right  through  the  mangled 
tissues.  I  employed  the  procedure  of  Larrey,  carefully  ex- 
cised the  nerves,  and  put  in  six  metallic  sutures.  At  the 
second  dressing,  which  was  made  on  the  fourth  day,  union 
seemed  to  be  complete.  The  stitches  and  drain  were  removed 
on  the  sixth  day.  At  no  time  did  the  dressings  cause  any 
pain. 

In  the  treatment  of  amputations,  it  is  particularly  important 
to  persist  in  the  dressings  until  cicatrization  is  perfect.  For 
lack  of  this  precaution,  one  often  meets  with  tedious  compli- 
cations, such  as  osteo-periostitis,  pain  in  the  stumps,  and 
fistules.  I  have  previously  mentioned  this  fact  in  speaking 
of  the  duration  of  the  dressings,  but  it  cannot  be  repeated  too 
much,  for  that  is  not  a  moderate  advantage  of  the  method 
which  protects  those  who  suffer  amputation  from  all  the  acci- 
dents which  are  likely  to  embitter  their  existence. 


CHAPTER    XVII. 

Wounds  of  Joints. —  Removal  of  Foreign  Bodies.  —  Operations 
FOR  Fractures  and  Dislocations.  —  Opening  of  Joints  for 
Hydrarthrosis.  —  Opening  of  Diseased  Joints.  —  Opening  of 
White  Swellings.  —  Antiseptic  Irrigation  of  Inflamed  Ar- 
ticulations. 

In  all  surgery  there  are  no  cases  which  more  thoroughly 
demonstrate  the  value  of  the  antiseptic  method  than  those 
involving  the  opening  of  joints.  Doubtless  it  sometimes 
happens  that  articular  wounds  heal  without  complication 
in  favorable  media ;  but  when  the  circumstances  are  bad,  it 
is  only  exceptionally  that  we  have  happy  results.  It  is  also 
true  that,  in  a  very  recent  period,  the  great  care  bestowed 
upon  surgery  has  had  the  effect  of  diminishing  the  accidents 
of  articular  injuries  ;  but  up  to  the  present  time  there  has 
been  no  surgeon  who  could,  without  anxiety,  contemplate  the 
opening  of  a  large  joint,  whether  the  result  of  accident  or 
made  by  the  surgeon  himself. 

Three  principal  accidents  are  feared  as  the  consequences  of 
such  wounds. 

First,  traumatic  arthritis,  so  likely  to  be  followed  by  rapid 
and  formidable  accidents,  general  involvement  of  the  system, 
purulent  infection,  and  speedy  death. 

Second,  interminable  suppurations,  within  and  around  the 
joints,  terminating  in  indefinitely  delayed  recovery,  or  death 
at  a  distant  date. 

Third,  loss  of  the  functions  of  the  joint,  if  healing  does 
take  place,  even  in  the  favorable  cases. 


INJURIES   OF   JOINTS.  133 

Just  imagine  that,  after  the  employment  of  the  antiseptic 
method,  the  wounds  do  not  inflame,  do  not  suppurate,  and 
that  purulent  infection  is  unknown,  and  you  will  understand 
how  it  is  that  the  healing  of  articular  wounds  has  become 
the  regular  thing,  and  that  the  opening  of  joints  by  the 
surgeon  deserves  to  rank  among  the  operations  which  are 
safe,  and  as  regards  death,  harmless. 

Articular  wounds. 

Wounds  of  joints  form  a  very  bad  class,  especially  if  they 
have  continued  a  considerable  time  without  proper  treatment, 
because  we  cannot  then  be  sure  of  expelling  the  germs  from 
all  the  recesses.  This  is  a  point  of  vital  importance.  The 
sinuosities  of  the  wounds  should  be  very  carefully  washed 
out  with  a  powerful  antiseptic,  the  strong  carbolic  acid  water 
ordinarily  answering  this  purpose.  In  certain  cases  a  stronger 
liquid  may  be  indicated,  and  then  we  may  use  a  twenty-per- 
cent, solution  of  carbolic  acid  in  alcohol.  In  these,  as  in  all 
tortuous  wounds,  the  injected  liquid  must  all  be  evacuated, 
or  else  there  may  be  excited  too  intense  irritation  and  the 
carbolic-acid  poisoning  which  has  sometimes  been  observed. 
Where  the  wounds  are  so  sinuous  that  it  is  difficult  to  purify 
them,  we  should  not  hesitate  to  lay  them  freely  open.  Great 
attention  should  be  bestowed  upon  the  stitches,  which  ought 
not  to  be  too  tight. 

Drainage  must  be  abundantly  provided,  and  it  is  better  to 
use  several  tubes  than  only  one.  If  the  wounds  are  very 
simple  and  straight,  they  will  rapidly  heal,  and  drainage  is  of 
brief  duration.  I  advise  never  closing  them  completely  at 
first.  When  they  are  not  simple  and  straight,  it  is  wise,  after 
withdrawing  the  drain,  to  close  them  only  when  the  serous 
secretion  is  very  moderate  in  amount. 


134  ANTISEPTIC    SURGERY. 

I  need  not  dwell  upon  the  practice  and  give  examples  of 
this  treatment,  because  it  differs  so  slightly  from  that  which 
I  have  recommended  in  case  of  compound  fractures,  espe- 
cially those  which  involve  the  joints. 

Operations. 

The  operations  which  are  performed  upon  healthy  articu- 
lations, or  those  which  are  nearly  so,  are  particularly  in- 
teresting. I  shall  make  no  reference  to  the  cases  in  which 
the  articulations  are  opened  in  the  course  of  an  operation  in 
the  vicinity,  and  those  in  which  an  exploratory  incision  is 
made,  as  proposed  by  Annandale. 

Removal  of  foreign  bodies. 

The  facts  concerning  the  direct  extraction  of  foreign  bodies 
from  joints,  laid  open  for  this  purpose,  are  certainly  very 
curious. 

We  know  how  good  reason  there  formerly  was  for  consid- 
ering this  an  operation  of  a  serious  character.  B.  Bell,  in- 
deed, thought  it  even  more  dangerous  than  amputation  of  the 
thigh  at  the  upper  third.  Now,  following  the  example  set 
by  Lister  ten  years  ago  in  Glasgow,  in  case  of  a  large  foreign 
body  in  a  joint,  Barwell,  in  London,  has  made  a  very  careful 
study  of  the  value  of  the  antiseptic  dressing.  But  Saxtorph, 
of  Copenhagen,  by  a  considerable  number  of  operations,  has 
shown  its  possible  success  better  than  anybody  else.  He  has 
reported  twelve  cases  with  only  one  death,  and  in  this  case, 
too  cruelly  illustrative,  the  patient  tore  off  the  dressing  and 
was  attacked  with  purulent  infection. 

Following  in  these  footsteps,  I  removed  at  the  Hospital  of 
Lariboisiere,  on  the  twenty-eighth  of  October,  1876,  a  large 


EXTE ACTION   OF   FOEEIGN   BODIES.  135 

foreign  body,  performing  a  very  unusual  operation,  that  of 
extracting  a  body  from  the  back  part  of  the  joint.  An  incision 
on  the  outside  of  the  popliteal  space  permitted  me  to  reach 
the  body,  which  was  deeply  situated.  The  patient,  a  man  of 
fifty-one  years,  had  only  four  dressings;  the  wound  was 
healed  in  nine  days,  and  he  could  support  himself  upon  the 
limb  in  three  weeks.  The  mobility  of  the  articulation  was 
not  in  the  least  impaired. 

The  points  to  be  observed  in  this  special  case  are  as  fol- 
lows :  make  a  free  opening ;  take  as  rpany  stitches  as  are 
necessary  to  effect  apposition,  and  take  them  deeply,  as  the 
tissues  in  this  region  are  generally  thick  from  close  intersec- 
tion. The  drainage  must  be  carefully  made,  and  it  should 
not  last  long.  In  my  opinion,  it  was  because  he  neglected 
drainage  in  the  first  place  that  Eugene  Bceckel  lost  the  patient 
whose  history  he  gave  in  the  Strasbourg  Medical  Gazette,  in 
October,  1877.  His  first  operation  was  successful,  but  in  the 
second  case  the  patient  succumbed  to  purulent  infection. 

I  consider  it  not  only  useless,  but  even  injurious,  to  rigor- 
ously immobilize  the  limb  after  the  operation.  I  put  it  all 
dressed  into  a  trough,  and  remove  it  at  each  dressing.  There 
is  little  need  of  renewing  the  dressing,  except  upon  the  first 
day.  The  operation  in  itself  is  simple.  The  wound  is  to  be 
washed  in  carbolic-acid  water,  which,  however,  should  not  be 
injected  into  the  joint.  Not  to  uselessly  irritate  the  articula- 
tion and  not  to  immobilize  it  are  two  important  factors  in  the 
prevention  of  all  tendency  to  ankylosis. 

Without  any  question,  this  is  the  operation  to  choose  in 
the  cases  where  there  are  foreign  bodies  in  joints.  The  op- 
eration of  Goyrand  is  difficult  and  murderous,  although  less 
serious  than  the  old  method  of  freely  laying  open,  as  has  been 
demonstrated  by  Verneuil. 


136  Ai^TISEPTIC    SUKGEEY. 

Operations  for  fractures  and  dislocations. 

There  are  certain  operations  upon  joints  which  are  nearly 
sound  which,  at  the  first  glance,  are  appalling.  Thus,  Lister 
has  often  opened  joints,  on  account  of  recent  or  old  fractures 
which  have  involved  them,  to  straighten  limbs,  as  after  luxa- 
tion of  the  foot ;  to  excise  pieces  of  vicious  callus,  as,  for 
example,  in  the  elbow  and  tibio-tarsal  joints ;  and,  finally,  to 
bring  together  by  suturing  the  two  widely  separated  frag- 
ments of  a  recently  broken  patella. 

Moreover,  we  must  reckon  under  the  head  of  articular 
wounds  the  operations  made  for  the  cure  of  irreducible 
luxations.  Volkmann  did  this  for  an  iliofemoral  dislocation 
of  two  months'  standing.  Not  having  succeeded  in  reducing 
the  luxation,  he  excised  the  head  of  the  femur,  and  his  pa- 
tient was  healed  by  immediate  union. 

Operation  for  hydrarthrosis. 

An  operation  which  seems  even  much  more  rash  is  often 
practised  by  Professor  Lister  upon  obstinate  hydrarthroses. 
At  first  it  was  a  singular  surprise  both  to  me  and  my  fellow 
assistant,  N.  Gueneau  de  Mussy,  in  one  of  Lister's  demon- 
strations, in  1875.  It  consisted  of  freely  opening  the  knee 
joint  in  a  case  of  persistent  hydrarthrosis,  of  carefully  empty- 
ing it,  even  inserting  the  fingers  to  accomplish  this,  and 
draining  by  the  method  described.  Thus  the  radical  cure  of  a 
hydrarthrosis  of  the  knee  was  accomplished  without  ankylosis. 
Through  Dr.  Rice,  then  interne  at  the  hospital,  I  had  news 
of  the  patient  referred  to  above.  He  was  completely  cured  at 
the  end  of  two  months,  and  walked  with  ease.  I  have  seen 
other  similar  cases,  and  Panas  successfully  performed  this 
operation  at  Lariboisiere. 


DISEASE   OF   JOINTS.  137 

The  opening  should  be  large  in  order  to  give  free  vent  to 
the  fluid.  The  outer  side,  being  more  dependent,  is  to  be 
preferred  for  the  incision.  The  sutures  should  be  taken  with 
precision,  and  should,  if  possible,  include  all  the  tissues,  even 
the  serous,  and  are  consequently  somewhat  difficult  to  insert. 
At  least  one  tube  is  required  for  drainage,  and  often  two  will 
be  needed.  The  patient,  as  above,  should  be  dressed  without 
complete  immobilization,  and  the  joint  moved  even  before  the 
wound  is  healed. 

The  opening  of  diseased  articulations  ;  suppuration. 

The  opening  of  diseased  articulations  gives  results  which 
one  would  be  far  from  anticipating.  When  there  is  pus  in  a 
joint,  a  free  opening  permits  the  evacuation  of  all  the  morbid 
products ;  sutures  are  made,  and  the  wound  closes,  healing  in 
from  fifteen  to  thirty  days.  Here  a  large,  bold  opening  should 
be  made  at  the  outer  side  of  the  patella,  if  possible ;  this  per- 
mits the  escape  of  the  pus  and  the  detachment  of  the  false 
membranes  ;  the  fingers  are  passed  under  the  patella,  to  ex- 
plore and  to  cleanse  the  parts  ;  and  carbolized  sponges  may  be 
introduced  into  the  joint  and  wiped  against  the  suppurating 
walls  without  fear  of  doing  harm. 

Strong  carbolic  water  should  be  freely  used  in  washing  out 
the  joint.  There  will  generally  be  considerable  bleeding 
during  these  proceedings,  but  it  need  give  no  anxiety.  The 
return  of  the  fluids  which  have  been  introduced  should  be 
most  strictly  accomplished.  After  this  the  wound  is  sewed 
up  and  drained  almost  exactly  as  in  a  case  of  chronic  dropsy 
of  the  joint. 

I  have  made  this  operation  five  times  with  remarkable  re- 
sults. At  the  Lariboisi^re,  in  January,  1877, 1  opened  a  knee 
for  purulent  arthritis  in  a  man  of  thirty-three,  who  was  suf- 

10 


138  ANTISEPTIC    SURGERY. 

fering  from  a  sort  of  purulent  infection.  In  this  case,  which 
I  have  seen  very  often  since,  the  results  of  the  operation 
v^^ere  very  simple.  In  twenty  days  the  knee  was  completely 
cicatrized,  and  in  three  months  flexion  of  the  leg  was  accom- 
plished with  entire  ease. 

At  the  same  hospital  and  in  the  same  year,  I  opened  the 
knee  of  a  man  whose  only  alternative  was  amputation  of  the 
thigh.  He  had  osteo-periostitis  of  the  femur,  attended  with 
the  detachment  of  a  great  deal  of  bone.  A  large  sequestrum 
and  a  number  of  completely  infected  abscesses  prevented  my 
maintaining  the  asepticity  of  this  wound  until  the  very  end 
of  treatment ;  but,  for  all  that,  after  some  months  the  patient 
walked  out  with  a  good  use  of  his  limb.  In  this  case,  recog- 
nizing the  previous  infection,  I  injected  into  the  cavity,  at 
several  different  times,  a  twenty -per-cent.  solution  of  carbolic 
acid  in  alcohol. 

Since  then  I  have  opened  a  knee  at  the  Maternity  for  a 
most  serious  arthritis  in  a  puerperal  woman.  The  patient 
was  nineteen  years  old  and  entered  for  her  lying-in  on  the 
ninth  of  July,  1878.  She  had  eclampsia,  and  was  delivered 
with  the  forceps.  After  a  little  an  eruption  broke  out,  and 
several  joints  were  seized  with  pain.  The  left  knee  became 
tumefied  and  extremely  painful,  chills  occurred  on  the  tenth 
of  August,  and  again  on  the  twentieth,  the  last  being  very 
violent.  The  limb  reached  an  enormous  size,  the  suffering 
was  atrocious,  and  rest  was  impossible.  The  puerperal  state 
and  the  extreme  gravity  of  the  local  lesion  constituted  a 
frightful  combination,  and  the  general  condition  was  miser- 
able. On  the  twenty-seventh  of  August,  an  opening  four- 
teen centimeters  long  was  made  on  the  outer  side  of  the 
joint.  The  pus  was  abundant,  the  false  membranes  thick, 
and  a  large  quantity  of  blood  escaped  into  the  articulation. 
The  suffering  instantly  disappeared.     At  the  end  of  twenty- 


FREE   OPENING   OP   THE   JOINTS.  139 

seven  days  the  joint  was  closed,  and  the  patient  got  up  at  the 
end  of  two  months.  Little  by  little  walking  became  easier, 
but  a  good  deal  of  stiffness  remained  in  the  joint  five  months 
after,  the  patient  refusing  to  allow  passive  motion  to  be  made. 
She  walked  very  well  without  fatigue,  gained  rapidly,  recov- 
ered all  her  movements,  and  found  herself  so  well  that  she 
was  unwilling  to  submit  to  even  a  little  operation  to  increase 
mobility. 

More  recently,  being  called  in  consultation  by  M.  S^e  at 
his  private  hospital,  I  opened  the  right  knee  of  a  young 
Creole  who  had  purulent  arthritis,  the  sequel  of  a  deep  angei- 
oleucitis  of  the  leg.  In  spite  of  the  general  and  local  unfa- 
vorable conditions,  we  obtained  the  best  result,  the  knee  being 
closed  in  fourteen  days,  with  no  deep  inflammation  of  the  leg, 
and  movement  of  the  articulation  already  being  established. 

M,  B.,  aged  twenty-two,  had  in  the  right  calf  an  enormous 
abscess  consecutive  upon  angeioleucitis  of  the  foot,  and  M. 
S^e  opened  it  on  the  fifteenth  of  November,  1878.  On  the 
twentieth  of  December,  the  patient  began  to  have  pain  in  the 
knee,  the  wound  in  the  calf  continuing  to  suppurate.  The 
rapid  swelling  of  the  articulation  and  the  repeated  chills  left 
no  doubt  as  to  the  presence  of  pus,  and  on  the  twenty- 
seventh  of  December  a  needle  was  inserted  and  a  moderate 
quantity  of  pus  evacuated.  Three  days  after,  the  knee  had 
attained  a  great  size,  and  the  general  state  was  bad.  An 
opening  ten  or  twelve  centimeters  long  was  made  on  the 
outer  side  of  the  joint,  and  was  followed  by  the  escape  of  pus 
and  false  membranes.  I  passed  my  fingers  into  the  articula- 
tion, washed  it  out  with  strong  carbolic  solution,  and  sewed 
up  the  wound,  excepting  the  upper  angle,  in  which  I  placed 
two  drains  side  by  side.  The  discharge  for  the  first  two  days 
was  abundant,  but  afterwards  there  was  merely  an  exudation 
of  serum.    The  drains  were  removed  on  the  ninth  of  January, 


140  ANTISEPTIC    SURGERY. 

1879,  the  sutures  on  the  tenth,  and  on  the  twelfth  cicatri- 
zation was  complete.  The  development  of  a  new  abscess  in 
the  calf  interfered  with  the  healing,  and  the  pain  which  it 
produced  prevented  the  patient's  permitting  sufficient  flexion 
of  the  knee.     However,  in  April  he  began  to  bend  it  well. 

At  the  Salpetri^re,  in  the  service  of  my  colleague,  M.  Ter- 
rier, I  operated  upon  a  woman  of  thirty-seven  years,  the 
beginning  of  whose  arthritis  dated  back  to  the  puerperal  con- 
dition, after  a  miscarriage  in  the  first  part  of  December,  1878. 
She  had  had  abscess  in  the  calf,  and  in  December,  June,  and 
January  she  developed  purulent  arthritis  in  the  left  knee. 
From  the  fifteenth  of  January  to  the  twenty-third  of  May 
she  was  under  the  care  of  Professor  Gosselin,  who  punctured 
the  knee  and  drew  out  some  pus.  On  the  twentieth  of  April 
she  entered  the  Salpetriere  in  the  service  of  M.  Terrier.  The 
left  lower  limb  was  in  a  very  serious  condition,  the  tumefac- 
tion being  enormous,  the  pain  unendurable,  the  fever  high. 
The  limb  was  actually  deformed,  the  fluctuating  accumulation 
rising  up  eighteen  centimeters  above  the  patella.  On  the 
twenty-third  of  April,  I  made  an  incision  eight  centimeters 
long  on  the  outer  side,  and  more  than  a  liter  of  pus  and  false 
membranes  gushed  out.  I  washed  out  the  cavity  without 
passing  my  fingers  under  the  knee-pan.  The  bleeding  was 
profuse.  I  made  another  incision  on  the  inner  side,  parallel 
to  the  first.  Then  I  sewed  them  up,  leaving  only  enough 
room  for  a  drain  on  each  side.  The  tracks  of  the  tubes  did 
not  cicatrize  until  the  thirteenth  of  June.  When  the  patient 
was  discharged,  on  the  twenty-sixth  of  July,  she  walked  well 
and  was  able  to  flex  her  leg  to  a  right  angle. 

I  dwell  upon  these  examples  in  order  to  give  the  reader  a 
proper  comprehension  of  his  resources.  It  may  be  claimed 
that  by  no  other  proceeding  could  such  results  have  been  ob- 
tained ;  and  yet  they  might  have  been  more  rapid,  for  almost 


INFLAMED   AETICULATIONS.  141 

all  the  operations  were  made  in  circumstances  which  were 
only  moderately  favorable,  and  in  services  where  the  attend- 
ants were  not  accustomed  to  this  mode  of  dressing. 

After. having  given  a  fair  trial  to  the  trough,  I  have  come 
to  the  conclusion  that  it  is  almost  useless,  and  that  immobili- 
zation may  be  dispensed  with  —  a  great  advantage  in  most 
cases,  since  it  enables  us  to  establish  motion  in  the  articula- 
tions almost  immediately.  In  the  numerous  cases  of  articular 
suppuration  and  of  epiphyseal  osteo-periostitis,  I  think  we 
may  practise  it  with  profit,  freely  opening  the  abscess  and 
boldly  trephining  the  diseased  bones. 

The  opening  of  white  swellings. 

An  operation  which  seems  to  give  excellent  results  is  that 
of  making  large  incisions  into  joints  which  are  attacked  with 
white  swellings.  Sometimes,  as  Lister  says,  this  suffices  to 
start  the  patient  on  the  road  to  recovery.  I  have  practised 
it  with  success.  If,  after  some  time,  there  is  no  amelioration 
of  the  patient's  condition,  resection  should  be  resorted  to. 

Unfortunately  I  have  not  been  able  to  keep  track  of  the 
patients  upon  whom  I  have  practised  such  incisions.  I  in- 
cised the  elbow  of  a  young  woman,  a  private  patient,  and  she 
got  along  admirably  during  the  two  months  I  was  able  to 
keep  watch  of  her.  Saxtorph  has  reported  cases  of  this  kind. 
Concerning  the  operation  itself  there  is  nothing  in  particular 
to  say,  as  it  does  not  materially  differ  from  that  for  articular 
abscess.  The  dressing  should  not  be  abandoned  until  cica- 
trization is  absolute. 

The  antiseptic  irrigation  of  inflamed  joints. 

Schede  has  recommended  an  operation  which  can  be  prac- 
tised freely  upon  inflamed  joints.     It  consists  in  puncturing 


142  ANTISEPTIC    SUBGERY. 

the  articulations  which  are  attacked  with  rheumatic  inflam- 
mation and  distended  with  excessive  secretion,  then  empty- 
ing them,  injecting  weak  carbolic  solution,  and  repeating  this 
injection  until  the  fluid  returns  clear.  The  canula  is  then 
withdrawn  and  the  limb  is  immobilized.  This  little  opera- 
tion, being  made  with  all  the  antiseptic  precautions,  is  with- 
out danger,  and  is  followed  by  relief  and  rapid  recovery.  It 
is  now  so  extensively  practised  in  Germany  that  it  is  even 
done  in  cases  of  acute  rheumatism,  when  there  is  much  swell- 
ing of  the  joints. 

The  manner  of  operating  is  as  follows :  all  the  antiseptic 
precautions  being  observed,  the  puncture  is  made  with  a 
medium-sized  trocar;  a  two-and-a-half  per  cent,  solution  of 
carbolic  acid  is  then  thrown  into  the  joint ;  after  this  escapes, 
another  injection  is  made,  and  this  process  is  repeated  until 
the  discharged  liquid  is  clear. 

After  the  operation  the  reaction  is  variable.  Some  patients 
have  none ;  others  have  some  swelling,  at  first  painful,  after- 
wards a  little  persistent. 

The  results  of  this  practice  are  excellent.  Carl  Rossander, 
of  Stockholm,  who  has  followed  Schede,  praises  it  highly. 
He  has  even  employed  it  in  the  case  of  a  child  a  year  and  a 
half  old. 


CHAPTER  XVIII. 

Kesection  of  Joints. 

For  a  long  time  French  surgery  hesitated  before  this  class  of 
operations:  for,  while  resections  of  the  elbow,  shoulder,  and 
ankle  were  often  practised,  those  of  the  knee  and  hip  were 
very  rare,  and  those  of  the  wrist  were  almost  entirelj''  avoided. 
The  legitimate  reluctance  of  conservative  surgery  ought  to 
give  way  before  the  antiseptic  method. 

Resections  may  be  rejected  on  account  of  the  immediate 
accidents  or  the  protracted  suppurations  which  follow  them; 
persisting  fistules  and  loss  of  the  functions  of  limbs  are  the 
direct  consequences.  Most  of  the  dangers  are  immediate, 
and  secondary  accidents  are  very  rare ;  and,  therefore,  we 
should  be  very  favorably  disposed  to  these  operations. 

Generally  they  present  nothing  in  particular  which  requires 
any  modification  of  the  dressing.  Nevertheless,  it  should  be 
remembered  that  we  have  to  treat  inflamed  joints  which  have 
not  and  those  which  have  exterior  openings.  Quite  natu- 
rally, in  the  latter  cases  it  is  much  more  difficult  to  obtain 
asepsis  ;  but  yet  we  can  secure  it  very  frequently  by  scraping 
the  suppurating  surfaces  with  a  curette.  In  these  cases, 
and  even  in  those  which  have  not  had  an  external  opening, 
it  is  always  necessary  to  carefully  remove  all  morbid  prod- 
ucts. This  is  the  one  step  in  the  procedure  upon  which  suc- 
cess depends.  The  fungosities  must  be  completely  destroyed  ; 
for,  if  they  are  left  in  place,  they  multiply  rapidly,  impede 
reunion,  and  provoke  suppuration.  The  surgeon  cannot  be 
too  scrupulous  in  cutting  them  away  even  to  the  last  traces. 


144  ANTISEPTIC    SURGERY. 

In  the  case  of  certain  articulations,  as  the  knee,  for  example, 
Volkmann  goes  much  further,  and  advises  the  careful  re- 
moval of  the  fibrous  tissues,  which  often  hinder  reunion.  The 
drainage  is  difficult,  and  it  should  be  made  with  the  utmost 
fastidiousness. 

For  resection  of  the  hip  and  shoulder  there  are  no  special 
indications.  I  have  seen  Lister  effect  drainage  with  horse- 
hair with  good  results.  Extension  may  be  practised  from  the 
beginning  of  the  treatment. 

In  the  knee  we  have  the  advantage  of  obtaining  solid 
union,  and  particular  pains  should  be  taken  to  avoid  non- 
union, which  makes  a  genuine  pseudarthrosis,  arising  from  the 
lack  of  inflammatory  reaction.  I  pointed  this  out  in  speak- 
ing of  the  treatment  of  false  joints. 

In  a  communication  to  the  Congress  of  German  Surgeons, 
Volkmann  recommended  suturing  the  osseous  surfaces.  He 
considers  the  catgut  the  best  material  for  this  purpose,  and 
leaves  it  permanently  in  the  wound.  Silver  and  iron  wire 
have  also  been  used  with  good  results. 

At  the  same  time,  Volkmann  advised  the  avoidance  of  the 
use  of  the  saw  in  articular  resections.  The  bones  of  people 
who  require  excision  can  be  cut  well  enough  with  the  knife, 
and  the  surface  obtained  in  this  way  is  much  better  adapted 
for  reunion,  as  the  action  of  the  saw  leaves  an  osseous  sur- 
face of  which  a  thin  layer  may  mortify. 

Excision  of  the  wrist  was  strongly  advised  by  Professor 
Lister  long  before  the  antiseptic  method  was  proposed ;  and 
so  it  was  all  ready  to  profit  by  the  resources  of  the  new  sys- 
tem. I  have  watched  his  patients  in  all  stages  of  treatment, 
from  the 'moment  of  operation  until  the  cure  was  complete. 
Here  the  object  of  the  surgeon  is  to  preserve  both  the  form 
of  the  hand  and  the  greatest  possible  amount  of  movement ; 
and,  therefore,  the  professor  recommends  the    employment 


EXCISION   OF  WRIST.  145 

from  the  first  of  a  kind  of  si3lint  of  cork  Avith  a  marked  con- 
vexity, upon  which  the  palm  of  the  hand  rests.  Then,  after 
a  few  days,  say  at  the  end  of  the  first  week,  he  makes  the 
patient  perform  the  various  movements  of  the  fingers  at  each 
dressing,  and  this,  he  says,  is  the  true  means  of  getting  good 
results  from  the  operation.  Thanks  to  the  asepticity  of  the 
wounds,  this  practice  of  movement,  at  a  very  early  date,  may 
be  employed  whenever  we  desire  to  have  a  movable  joint 
after  resection. 

The  most  salient  circumstance  in  the  progress  of  wounds 
of  this  sort  is  the  extraordinary  rapidity  of  repair,  in  illustra- 
tion of  which  I  may  mention  a  knee  healed  in  fifteen  days 
under  the  care  of  Professor  Lister.  Auguste  Reverdin  re- 
cently reported  to  me  that  he  had  actually  observed  in  these 
cases  union  by  first  intention.  He  had  seen  a  child  in  Volk- 
mann's  service,  w^hose  wounds  were  cicatrized  in  five  days 
after  resection  of  the  hip. 


CHAPTER    XIX. 

Peritoneal  Operations.  —  Strangulated  Hernia.  —  Radical 
Cure  op  Hernia.  —  Laparotomy.  —  Ovariotomy.  —  Cesarean 
Section.  —  Porro's  Operation.  —  Cysts  op  the  Liver. 

All  operations  which  involve  the  peritoneum  have  a  common 
character,  whatever  differences  they  may  present ;  and  I  in- 
troduce them  in  the  same  chapter,  because  the  antiseptic 
method  is  similarly  advantageous  in  all  of  them.  If  the 
method  is  rigorously  practised,  the  opening  of  this  great  se- 
rous cavity  is  deprived  of  its  proverbial  seriousness.  Steam 
spray-producers  are  particularly  necessary  in  these  cases,  and 
those  apparatuses  which  chill  or  wet  these  great  uncovered 
surfaces  too  much  are  objectionable. 

Kelotomy ;   operations  for  strangulated  hernia. 

In  the  front  rank  of  operations  which  every  practitioner  is 
called  upon  to  make  we  must  place  that  performed  for  strangu- 
lated hernia.  I  have  done  it  a  great  many  times  with  the  anti- 
septic method,  and  the  results  have  been  excellent,  though 
sometimes  almost  unhoped  for.  As  there  is  no  local  inflam- 
matory reaction,  the  chances  of  peritonitis  are  insignificant, 
the  repair  of  the  injured  parts  is  accomplished  more  rapidly 
and  regularly,  and  the  reduction  of  the  rupture  is  allowable 
even  when  the  appearance  of  the  intestine  is  very  unprom- 
ising. 

I  had  been  previously  pretty  fortunate  in  my  hernia  oper- 
ations, in  which,  however,  I  always  employed  antiseptic 
washings  and  closure  of  the  wound  ;  but  I  never  happened 


STRANGULATED   HERNIA.  147 

to  have  six  cures  one  after  another,  as  occurred  in  the  year 
1877,  under  the  antiseptic  treatment ;  and  of  these  six  some 
were  miserable  cases,  both  as  regards  the  age  of  the  patients 
and  the  duration  of  the  strangulation.  Since  I  began  to  use 
the  Lister  method,  I  have  lost  only  those  cases  in  which  there 
was  so  serious  an  injury  to  the  knuckle  of  intestine  that  per- 
foration rapidly  took  place.  My  operations  have  been  only 
on  persons  brought  tardily  to  the  hospital  by  day  or  night, 
generally  after  having  been  subjected  to  violent  and  pro- 
longed taxis,  and  it  is  on  this  account  that  six  consecutive 
cures  are  so  remarkable. 

The  irritant  action  of  the  carbolic  acid  upon  the  perito- 
neum has  been  dreaded  ;  and  yet  it  is  marvellous  to  see  that 
a  solution,  so  strong  as  to  destroy  the  epidermis  on  the 
operator's  hands,  is  borne  by  the  peritoneum  without  in- 
convenience. 

In  the  operation  for  strangulated  hernia,  in  addition  to 
the  ordinary  precautions,  I  recommend  a  large  opening,  so  as 
to  completely  uncover  the  sac.  As  soon  as  the  sac  is  opened, 
its  cavity  should  be  washed  out  several  times  with  the  strong 
solution  in  order  to  neutralize  the  products  of  inflammation 
or  hemorrhage  of  the  sac  and  get  them  out  of  the  way.  Then 
we  proceed  to  the  removal  of  the  constriction,  which  being- 
done,  the  loop  of  intestine  is  carefully  washed  with  the  weak 
carbolic  solution,  before  being  returned  to  the  abdomen. 
With  it  some  of  the  carbolized  water  always  enters  the  ab- 
dominal cavity,  but  it  is  of  no  consequence.  Before  the 
suture  is  made,  I  advise  the  excision  of  the  greater  part  of 
the  sac,  as  this  proceeding  greatly  facilitates  union,  and  is  of 
advantage  with  reference  to  a  radical  cure.  Great  care 
should  be  devoted  to  the  stitches.  For  a  long  time  I  have 
been  in  the  habit  of  taking  a  deep  stitch  at  the  level  of  the 
ring.     This  practice  favors  radical  cure,  but  it  requires  a 


148  ANTISEPTIC    SURGERY. 

great  deal  of  watchfulness,  because  it  is  followed  by  a  little 
swelling.  A  single  drainage-tube  suffices,  except  in  large 
scrotal  hernias.  There  is  no  need  of  keeping  the  tube  in  a 
long  time ;  it  should  be  removed  some  time  between  the 
fourth  and  eighth  days  ;  and  thus  the  cure  of  a  strangulated 
hernia  does  not  generally  take  more  than  from  eight  to 
twelve  days. 

In  this  way  the  operation  is  made  with  great  ease,  and  with 
entire  absence  of  concern  as  regards  proximity  to  the  perito- 
neum ;  indeed,  in  my  hospital  services,  I  always  give  the 
students  a  good  understanding  of  the  operation,  by  making 
them  put  their  fingers  into  the  wound,  and  even  into  the 
peritoneum,  behind  the  open  ring,  provided  they  have 
cleansed  their  hands  in  my  presence.  Sometimes  there  are 
seven  or  eight  around  me  who  make  this  deep  examination, 
which  has  never  yet,  to  my  knowledge,  resulted  in  any 
harm. 

Several  times  cases  in  which  the  intestine  was  injured  and 
even  perforated  have  presented  themselves.  Panas  once  had 
occasion  to  apply  a  ligature  like  the  string  of  a  purse  to  an 
intestine  which  had  become  gangrenous  at  one  point ;  then 
he  reduced  the  hernia,  and  the  patient  made  a  good  recovery. 

I  have  always  taken  advantage  of  the  occasion  for  this 
operation  to  make  that  for  radical  cure,  and  whenever  there 
are  large  masses  of  omentum,  I  cut  them  off,  and  reduce  the 
one  or  more  pedicles  tied  with  catgut. 

I  have  generally  made  the  sutures  with  silver  wire,  but  I 
have  also  used  catgut,  and  have  very  lately  had  an  excellent 
result  in  the  case  of  a  woman,  who  was  out  of  bed  in  less 
than  three  weeks  after  the  operation. 

As  regards  the  dressing,  I  would  particularly  direct  the 
attention  of  the  reader  to  the  difficulties  of  applying  it  in  the 
fold  of  the  groin.    We  have  to  make  it  thick  and  to  complete 


OPERATION   FOE.   RADICAL   CURB.  149 

it  at  the  edges  with  boracic  wadding  or  lint.  The  amount  of 
discharge  is  so  moderate  that  very  infrequent  dressings  will 
be  found  sufBcient.  The  early  omission  of  the  drainage  and 
the  use  of  catgut  for  sutures  are  favorable  to  rapidity  of 
healing. 

In  order  to  insure  the  maintenance  of  the  radical  cure,  I 
always  make  the  patients  wear  a  bandage  for  some  time  after 
the  operation.  It  seems  to  me  that,  since  I  have  employed 
the  proceeding  indicated,  the  radical  cure  has  been  the  rule, 
while,  in  my  first  operations,  recurrence  of  the  difficulty  was 
most  common. 

Radical  cure  of  hernia. 

This  operation  will  soon  take  its  place  in  the  rank  of 
legitimate  surgery,  both  on  account  of  the  security  acquired 
by  the  employment  of  Listerism,  and  from  the  possibility  of 
employing  without  hesitation  convenient  and  really  effica- 
cious methods.  The  publications  on  this  subject  are  already 
numerous. 

One  of  the  first  and  most  brilliant  of  the  published  results 
was  that  of  my  friend  and  companion.  Dr.  Chiene,  of  Edin- 
burgh, who  effected  the  radical  cure  of  immense  epiploic 
hernise. 

The  essential  steps  of  the  operation  are  as  follows:  incision 
of  the  sac  ;  subdivision  of  the  pedicle  of  the  epiploic  mass 
into  little  bundles,  each  of  which  is  tied  with  catgut ;  excision 
of  the  omentum  below  the  ligature.  This  being  done,  the 
pedicles  are  reduced.  The  whole  of  the  sac  is  resected,  the 
neck  is  closed  by  deep  catgut  sutures  close  to  the  ring,  then 
superficial  silver  sutures  are  inserted,  and  drainage  effected 
as  in  case  of  strangulated  hernia.  Chiene  has  made  this 
operation  successfully  several  times  already. 

I  myself  pursued  this  plan  in  taking  advantage  of  a  keloto- 


150  ANTISEPTIC    SURGERY. 

my  made  for  a  left,  strangulated,  crural  hernia,  accompanied 
by  an  omental  mass  as  large  as  my  fist.  I  relieved  the  constric- 
tion, reduced  the  strangulated  knuckle  of  intestine,  divided 
the  epiploic  pedicle  into  seven  fasciculi,  excised  the  entire 
mass,  and  replaced  the  pedicle  within  the  ring.  Then  I  cut 
away  all  the  sac,  and  sewed  up  the  neck  with  deep  silver 
stitches.  The  patient  was  cured  in  three  weeks ;  and  when 
I  examined  her,  several  months  afterwards,  she  had  had  no 
return  of  the  rupture.  The  catgut  threads  had  been  cast  out, 
which  I  attributed  to  the  premature  abandonment  of  the 
dressing ;  the  patient  was  not  in  my  own  service,  and  I  did 
not  personally  superintend  her  case.  Three  months  after,  I 
did  the  same  operation  upon  a  woman  sixty  years  old,  who 
was  up  and  about  in  three  weeks,  wearing  a  bandage. 

Dr.  Henry  O.  Marcy,  of  Cambridge,  Massachusetts,  has 
published  an  interesting  treatise,  in  which  he  recommends 
operating  without  opening  the  sac.  The  sac  being  exposed, 
he  replaces  it  within  the  ring  with  his  finger,  and  fastens  it 
in  place  with  catgut  sutures,  passing  them  at  the  level  of  the 
neck.  This  operation  he  has  performed  twice  in  cases  of 
strangulated  hernia  and  once  in  an  uncomplicated  hernia, 
with  complete  success  in  the  first  two,  and  partial  in  the 
last. 

The  most  complete  publication  is  that  of  Professor  Tilanus, 
of  Amsterdam.  He  shows  by  statistics  that  the  operation  for 
radical  cure,  even  when  performed  antiseptically,  is  not  abso- 
lutely free  from  danger,  and  he  thinks  that  it  ought  to  be 
employed  only  in  irreducible  or  otherwise  complicated  hernise. 
In  performing  it,  he  advises  the  excision  of  the  sac,  the  suture 
of  the  deep  parts  about  the  neck,  and  a  superficial  suture. 
He  has  tried  the  plan  of  not  making  the  patients  wear  a  ban- 
dage immediately  afterwards,  but  his  experience  was  not 
satisfactory,  and  he  now  favors  the  use  of  the  bandage.     He 


UMBILICAL   HERNIA.  151 

does  not  approve  of  complicated  procedures,  and  considers 
the  use  of  injections  as  insufficient.  Tilanus's  work  reviews 
all  the  important  facts  which  bear  upon  this  subject,  partic- 
ularly those  brought  forward  by  Czerny. 

The  same  dressings  should  be  used  as  in  strangulated 
hernia.  It  is  a  good  plan  to  make  a  number  of  incisions 
about  the  ring,  a  sort  of  scarification.  This,  combined  with 
complete  excision  of  the  sac,  permits  the  deep  suture  to  effect 
an  approximation  of  surfaces  which  are  raw  and  bloody. 
Drainage  is  called  for,  but  should  be  dispensed  with  as  soon 
as  possible.  The  deep  suture  which  includes  the  ring  may 
be  made  either  by  tying  the  two  ends  and  leaving  them  deep 
in  the  wound,  or  by  bringing  the  two  principal  threads  out  and 
securing  them  on  the  skin,  which  is  my  method  of  doing  it. 
The  suture  should  be  carefully  watched,  as  it  sometimes  ex- 
cites swelling.  The  stitches  are  much  more  easily  taken  in 
inguinal  hernia. 

Umbilical  hernia  affords  an  especial  opportunity  for  anti- 
septic surgery.  It  is  no  longer  a  matter  of  such  gravity  as  it 
was  formerly,  and  the  excision  of  the  sac  is  particularly  easy. 
We  know  that  in  ovariotomy,  when  there  is  a  co-existent 
umbilical  hernia,  it  is  the  rule  to  excise  the  sac  and  the  ad- 
jacent skin;  it  is  a  simple  procedure  for  radical  cure  which 
should  be  used  in  cases  of  umbilical  hernia. 

Professor  Carl  Rossander,  of  Stockholm,  performed  very 
nearly  this  operation  for  umbilical  hernia  in  a  child  of  two 
years,  in  1878.  He  opened  the  sac,  excised  the  omentum, 
ligatured  the  sac,  retrenched  it  and  the  pouch  of  skin,  and 
sewed  up  with  catgut,  using  no  drain.  The  cure  was  imme- 
diate ;  and,  several  months  afterwards,  there  had  been  no 
return  of  the  difficulty. 


152  ANTISEPTIC    SUKGERY. 

Laparotomy  for  internal  strangulation. 

The  opening  of  the  abdomen  to  seek  for  the  seat  of  a 
strangulation,  whether  we  are  guided  by  the  data  of  an  exact 
diagnosis  or  proceed  very  much  at  random,  has  become  an 
excellent  operation,  for  the  reason  that,  on  the  one  hand, 
large  abdominal  incisions  are  no  longer  serious,  and,  on  the 
other,  even  prolonged  search  under  antiseptic  protection  does 
not  tend  to  awaken  inflammation.  This  is  the  opinion  of 
almost  all  surgeons  who  are  familiar  with  the  antiseptic 
method,  and  antiseptic  laparotomy  has  achieved  numerous 
successes  in  England,  Germany,  and  Denniark. 

My  colleague  and  friend.  Dr.  Terrier,  in  1877,  made  at  the 
Bicetre  a  laparotomy  for  internal  strangulation  upon  an  old 
man  of  sixty-three  years.  In  spite  of  his  alarming  condition, 
the  patient  was  completely  cured  in  ten  days. 

Kecently  I  assisted  Dr.  Terrier  in  a  laparotomy  on  a  young 
woman  of  twenty-one,  two  months  after  her  accouchement. 
She  had  well-located  pain  of  an  unbearable  character,  vomit- 
ing, a  pinched  countenance,  and  low  temperature.  Both  of 
us  diagnosticated  strangulation  by  a  loop  of  peritoneum.  The 
incision  was  made  in  the  linea  alba.  There  was  bloody 
serum  in  the  abdominal  cavity.  The  operation  was  very 
laborious  and  occupied  nearly  an  hour  and  a  half.  Dr. 
Terrier  was  obliged  to  pull  out  a  large  part  of  the  intestines 
before  he  could  reach  the  constriction,  which  was  found  in 
the  true  pelvis.  It  was  lifted  up  on  two  fingers  and  torn, 
and  the  abdomen  was  rapidly  sponged  and  closed.  The 
patient  recovered  in  a  few  days,  and,  after  the  operation, 
complained  of  no  pain  in  her  belly.  In  this  case,  as  in  the 
former,  the  spray  was  furnished  by  my  apparatus.  The 
operation  was  made  in  the  common  ward,  without  removing 
the  patient  from  her  bed. 


LAPAROTOMY  FOR   STRANGULATION.  153 

These  two  cases  may  be  taken  as  remarkable  types ;  analo- 
gous cases  are  easily  found  to-day.  Antiseptic  laparotomy 
for  invagination  of  the  intestines  has  often  been  performed  ; 
the  gut  having  been  unwound,  the  cure  is  immediate. 

We  should  also  remember  the  beautiful  operation  of  Studs- 
gaard,  of  Copenhagen,  who,  in  a  case  where  a  glass  vase  had 
been  put  into  the  rectum  and  had  passed  into  the  colon, 
whence  it  could  not  be  extracted  through  the  natural  pas- 
sage, incised  the  abdominal  wall,  opened  the  intestine, 
removed  the  foreign  body,  sewed  up  the  bowel  with  catgut, 
returned  it  to  the  belly,  and  closed  the  external  wound.  The 
patient  recovered  rapidly. 

The  antiseptic  method  has  made  this  searching  for  foreign 
bodies  a  practical  and,  in  difl&cult  cases,  a  valuable  resource. 

In  operations  of  this  kind,  certain  directions  should  be  fol- 
lowed. To  have  them  successful  and  rapid,  we  must  make  a 
bold  incision  in  the  abdominal  wall,  and  I  advise  making 
it  always  in  the  median  line.  As  I  have  remarked  elsewhere, 
these  large  incisions  give  us  a  chance  to  search  without  hin- 
drance from  the  intestines,  even  when  they  are  tympanitic. 
Several  incidents  in  my  own  experience  warrant  me  in  mak- 
ing this  assertion ;  but  I  have  never  had  better  proof  of  it 
than  in  a  laparotomy  which  I  made  on  an  old  woman  of 
eighty,  who  had  an  internal  strangulation  coincidently  with 
an  uncomplicated  hernia.  The  tympanites  was  enormous.  I 
made  a  large,  median  incision,  and  readily  reached  the  con- 
striction. Unfortunately,  such  was  the  condition  of  the  in- 
testine that  there  was  no  chance  for  a  successful  result ;  but 
I  had  found  an  almost  easy  operation,  where  I  had  feared  it 
would  be  difficult. 

The  draining  of  a  little  carbolized  water  into  the  peritoneal 
cavity  is  not  a  matter  of  great  moment ;  but,  nevertheless,  it 
is  prudent  to  cover  the  edges  of  the  wound  with  moist  com- 

11 


154  ANTISEPTIC    SUKGERY. 

presses,  which  will  prevent  the  too  abundant  entrance  of  this 
liquid  into  the  abdomen.  All  the  viscera  which  are  exposed 
to  the  air  ought  to  be  scrupulously  washed  with  the  weak 
solution.  The  ligatures  may  be  made  of  fine  carbolized  silk, 
or,  better  still,  of  good  catgut. 

Finally,  in  the  majority  of  cases,  drainage  is  useless.  We 
close  the  abdomen  completely,  as  in  ovariotomy  after  the 
pedicle  has  been  dropped  back  into  the  cavity. 

Ovariotomy. 

It  was  obvious  that  ovariotomy  would  be  happily  influ- 
enced by  the  antiseptic  method.  I  do  not  know  who  first 
made  a  complete  application  of  it;  perhaps  it  was  Newman 
in  1872.  Nussbaum,  of  Munich,  seems  to  have  been  one  of 
the  first  to  practise  it  thoroughly,  using  the  spray,  bathing 
the  peritoneum  with  the  weak  solution,  and  draining  the  ab- 
domen with  a  bundle  of  eight  tubes  inserted  upright  near  the 
pedicle.  Immediately  his  results,  which  had  been  no  more 
than  moderately  good  up  to  that  time,  became  excellent;  he 
cured  eight  patients  in  succession,  a  thing  which  had  never 
happened  to  him  before.  Volkmann  made  an  operation  in 
1873.  Howitz,  of  Copenhagen,  began  in  December,  1875,  in 
his  seventy-seventh  operation.  He  had  been  having  a  series 
of  hopeless  failures ;  he  adopted  the  method,  and  at  once  had 
nine  consecutive  successes. 

In  Germany,  ovariotomy  never  gave  anything  but  moder- 
ate results  until  the  antiseptic  method  was  introduced ;  and 
the  most  brilliant  evidence  of  the  advantages  of  Listerism  is 
in  the  article  of  Schrceder  (^Berliner  KliniscTie  Wochenschrift, 
18,  March,  1878)  on  fifty  antiseptic  ovariotomies,  in  which 
he  shows  that  the  mortality  was  reduced  from  fifty  to  twenty 
per  cent. 


Keith's  ovabiotomies.  155 

The  documents  upon  this  subject  are  now  very  numerous, 
and  it  would  be  necessary  to  devote  a  considerable  chapter  to 
their  mere  enumeration,  for  almost  every  country  contrib- 
utes some.  I  must  content  myself  with  pointing  out  two 
articles  of  capital  importance,  which  are  to  be  found  in  the 
British  Medical  Journal  for  the  19th  of  October,  1878. 

The  first  is  by  one  of  the  surgeons  of  the  Samaritan 
Hospital,  which  has  been  made  so  celebrated  by  the  opera- 
tions of  Spencer  Wells,  and  is  entitled.  Fifty  cases  of  com- 
plete ovariotomy,  with  remarks  upon  six  other  cases  of  opening 
the  abdomen,  by  Knowsley  Thornton.  The  author,  who  was 
Professor  Lister's  interyie  before  he  became  Spencer  Wells's 
assistant,  shows  that,  from  the  very  day  on  which  he  adopted 
the  antiseptic  method,  his  operations  were  much  improved, 
and  while  his  first  twenty-five  cases  gave  seven  deaths,  that 
is,  twenty-eight  per  cent.,  the  following  fifty,  for  the  most 
part  by  the  antiseptic  method,  gave  four  deaths,  that  is  to 
say,  eight  per  cent. 

The  other  article  is  still  more  important,  being  from  the 
Scotch  ovariotomist,  Keith,  who  has,  up  to  the  present  time, 
obtained  the  most  beautiful  results  known.  He  narrates  how 
he  tried  the  antiseptic  method  at  first  without  the  spray,  and 
his  results  were  less  satisfactory  than  by  his  ordinary  practice. 
He  renounced  this  plan,  and  substituted  the  perfect  anti- 
septic method,  including  the  spray.  Before  that,  the  mor- 
tality in  fourteen  years  had  been  one  in  seven,  and,  for  the 
year  immediately  preceding,  one  in  twenty-one.  The  first 
forty-nine  cases  with  the  full  antiseptic  method  gave  him  two 
deaths,  which  occurred  in  the  first  eight  cases.  He  had  op- 
erated on  forty-one  consecutive  cases  without  a  death.  The 
two  fatal  cases  were  of  so  exceptional  gravity  that  he  would 
probably  not  have  attempted  them  without  the  antiseptic 
method. 


156  ANTISEPTIC    SURGERY. 

In  Keith's  opinion,  the  method  has  diminished  the  mor- 
tahty.  The  security  which  it  gives  warrants  operation  at  an 
earher  date.  Drainage  is  less  frequently  necessary,  and  may 
be  more  speedily  dispensed  with.  Convalescence  is  more 
rapid.  The  operation  is  much  easier,  and  the  proceedings  for 
the  purification  of  the  person  and  instruments  are  simpler. 
Finally,  says  Keith,  the  best  proof  that  the  spray  is  necessary 
in  ovariotomy  is  my  previous  experience  with  the  antiseptic 
method  so  many  years  without  the  spray. 

The  application  of  the  antiseptic  method  in  ovariotomy 
may  be  made  in  two  distinct  conditions — where  the  ]3edicle 
is  kept  outside,  and  where  it  is  returned  to  the  peritoneal 
cavity.  It  is  easily  seen  that  the  latter  facilitates  the  appli- 
cation of  the  method. 

Ovariotomy  is  done  in  the  ordinary  way  with  a  good  steam- 
atomizer.  All  the  catgut  ligatures  are  cut  short  and  left  in 
the  cavity.  The  pedicle  is  subdivided  and  tied  with  silk  or 
catgut.  Drainage  is  effected,  as  in  the  past,  by  an  upright 
glass  tube,  through  which  the  fluids  may  be  aspirated  from 
time  to  time.  This  tube  should  be  capped  with  an  antiseptic 
sponge  well  wrung  out.  Nussbaum  has  used  a  bundle  of 
eight  caoutchouc  tubes  for  a  drain,  withdrawing  one  or  two 
at  each  dressing.  Vaginal  drainage  appears  generally  to  be 
a  bad  proceeding. 

I  have  not  had  a  large  personal  experience  in  complete 
antiseptic  ovariotomy,  having  done  it  but  three  times.  Two 
of  these  patients  rapidly  recovered ;  the  third,  whose  general 
condition  was  deplorable,  rapidly  sank  and  died. 

I  have  made  one  hysterotomy  with  ablation  of  both  ovaries 
for  a  rapidly  growing  sarcoma.  The  patient  was  in  a  most 
satisfactory  condition,  both  general  and  local,  after  the  oper- 
ation ;  but  strangulation  took  place,  and  she  died  almost 
suddenly  on  the  fifth  day. 


OVARIOTOMY  IN  FRANCE.  157 

In  France,  the  antiseptic  method  was  not  at  first  rigorously- 
applied  in  ovariotomy.  Lately,  my  colleagues.  Terrier  and 
Pdrier,  after  having  for  some  time  employed  only  its  princi- 
pal precautions,  have  adopted  it  in  all  its  completeness.  It 
is  hard  to  determine  the  share  of  the  method,  for  the  success 
was  great  all  through :  twenty  of  Terrier's  twenty -two  cases 
were  successful,  and  all  of  Pdrier's  eight.  Moreover,  P^rier 
last  3^ear  removed  both  ovaries  and  the  entire  uterus,  dis- 
tended with  an  enormous  myoma  which  filled  the  abdomen, 
necessitating  an  incision  which  extended  almost  to  the  ensi- 
form  cartilage.  The  operation  was  thoroughly  antiseptic, 
and  the  woman  recovered  without  accident. 

In  making  an  ovariotomy,  the  operator  should  take  pains 
to  keep  any  considerable  amount  of  carbolized  v/ater  from 
entering  the  abdomen,  and,  if  any  does,  to  sponge  it  carefully 
away  at  once.  During  the  operation,  compresses  saturated 
with  weak  solution  should  constantly  be  used  for  the  protec- 
tion of  the  incision  and  the  viscera.  Silk  or  catgut  may  be 
used  for  ligatures.  In  an  immense  majority  of  cases,  drain- 
age may  be  dispensed  with.  It  is  even  dangerous,  if  the 
dressing  is  not  proper.  Without  drainage  the  dressing  is 
extremely  simple :  above  the  protective,  several  layers  of 
moist  gauze  ;  then  a  very  generous  amount  of  dry  gauze ; 
and  over  this  a  mass  of  wadding.  The  dressing  rarely 
requires  to  be  renewed,  except  in  case  of  pain. 

It  has  seemed  to  us,  as  to  Keith,  that  those  patients  who 
recover  excellently  have  a  little  greater  elevation  of  tempera- 
ture on  the  first  day  than  patients  used  to  before  the  method 
was  adopted ;  but  that  is  common  to  all  antiseptic  operations 
where  large  surfaces  are  exposed. 


168  ANTISEPTIC    SURGERY. 

Cesarean  section  and  Porro's  operation. 

The  antiseptic  method  has  enabled  us  to  revive  the  Csesa- 
rean  operation  in  cities,  and  successful  cases  have  already 
been  published. 

Disinfection  of  the  vagina  and  uterus  is  very  difficult,  and 
perhaps  the  security  will  never  be  absolute,  but  considerable 
gain  may  be  made.  In  these  cases,  in  addition  to  all  the  pre- 
cautions relative  to  the  abdominal  wall,  the  vagina  should  be 
washed  out  with  repeated  injections  of  strong  carbolized 
water ;  a  compress,  saturated  with  the  weak  solution,  should 
be  laid  upon  the  vulva,  and  frequently  renewed. 

The  operation  is  like  ovariotomy.  The  uterus  is  to  be 
incised  in  place,  and,  after  the  delivery  of  the  child  and 
placenta,  the  wound  is  to  be  closed  with  sutures.  This  may 
be  done  with  good,  large  catgut.  It  has  been  said  that  they 
cut  out ;  but  it  is  probable  that,  in  these  cases,  the  thread 
was  too  fine,  and  particularly  that  the  stitches  did  not  go 
deeply  enough  into  the  walls.  Abdominal  drainage  should 
only  be  made  with  short  tubes,  placed  in  the  lower  angle  of 
the  wound ;  and  it  would  be  imperfect,  if  retraction  of  the 
uterus  were  to  take  place.  According  to  circumstances,  the 
drainage  will  be  abdominal  or  vaginal. 

The  minutest  precautions  must  be  observed  with  reference 
to  micturition  and  defecation,  especially  in  the  first  days. 
Thick  tampons  of  gauze  and  even  carbolized  sponges,  care- 
fully separated  from  the  skin,  may  be  employed  with  ad- 
vantage. 

I  have  had  some  experience  in  the  operation  of  Porro," 
which  is  Csesarean  section  followed  by  excision  of  the  body 
of  the  uterus.  Last  March,  Tarnier  performed  it  in  the 
midst  of  students  in  the  great  amphitheatre  of  the  Maternity, 
a  place  which  is  not  considered  healthful,  to  say  the  least. 


PORRO'S   OPERATION.  159 

He  requested  me  to  take  charge  of  the  antiseptic  manoiuvres, 
which  were  as  follows:  the  preparation  of  the  abdominal 
surface  as  for  ovariotomy ;  repeated  vaginal  injections  with 
strong  carbolic  solution  ;  the  application  of  carbolized  com- 
presses to  the  vulva ;  in  the  course  of  the  operation,  after  the 
incision  of  the  uterus,  the  very  careful  toilette  of  the  perito- 
neum with  carbolized  sponges ;  the  application  of  a  knot  of 
iron  wire  to  the  pedicle ;  scrupulous  dressing  with  gauze. 
After  the  operation,  a  carbolized  compress  was  kept  upon  the 
vulva.  The  healing  was  rapid ;  the  antiseptic  dressing  was 
not  discontinued  until  the  wound  had  become  insignificant. 

It  is  much  easier  to  attain  perfect  asepticity  in  this  opera- 
tion than  in  Csesarean  section,  and  this  is  certainly  one  of  the 
greatest  inducements  to  choose  it.  While  nobody  has  known 
of  a  successful  case  of  Csesarean  section  in  Paris  for  a  hun- 
dred years,  the  antiseptic  method  has  given  us  success  in  an 
equally  formidable  operation  in  a  hospital  amphitheatre.  I 
have  nothing  to  add  to  the  description  of  the  precautions 
taken  in  ovariotomy  and  laparotomy,  excepting  the  purifica- 
tion of  the  vagina.  ^ 

Since  this  operation  was  first  performed  by  Porro,  of  Pavia, 
in  May,  1876,  it  has  been  made  but  seven  times  in  France : 
once  by  Fochier,  of  Lyons,  in  February,  1879,  mother  and 
child  being  saved ;  twice  by  Tarnier,  of  Paris,  the  mothers 
being  saved,  and  the  infants  dead  before  the  operation  was 
begun ;  and  four  times  by  myself,  with  the  result  of  bringing 
into  the  world  four  living  children,  and  saving  two  of  the 
mothers.  Of  the  infants,  two  are  yet  alive  and  well ;  one 
was  killed  by  criminal  carelessness  ;  and  the  last,  which  was 
very  feeble  from  its  birth,  died  in  four  days.     The  two  sur- 

1  The  description  of  the  author's  four  Porro's  operations  which  fol- 
lows is  taken  from  a  report  which  he  sent  to  the  translator  in  April, 
1881. 


160  ANTISEPTIC    SUEGEET. 

viving  mothers  are  in  excellent  health,  and  I  presented  them 
at  the  Academy  of  Medicme  in  March,  1880,  when  I  reported 
all  my  cases. 

By  a  singular  chance  these  four  cases  of  extreme  contrac- 
tion came  under  my  observation  in  the  space  of  two  months. 
In  each  there  was  a  rachitic  pelvis,  with  a  conjugate  diameter 
of  about  six  centimeters  or  less. 

The  first  patient  was  twenty-six  years  old,  primiparous,  one 
meter  and  a  quarter  tall,  with  a  sacro-sub-pubic  diameter  of 
seventy-three  millimeters  —  a  typical  rachitic  case.  During 
the  last  three  weeks  of  her  pregnancy  I  had  her  under  my 
care  at  the  Maternity.  Labor  began  in  the  morning  of  the 
nineteenth  of  November,  1879,  and  the  operation  was  per- 
formed in  the  afternoon  of  that  day,  every  precaution  having 
been  taken.  The  bag  of  waters  had  not  broken,  there  was  a 
slight  bloody  discharge,  and  the  cervix  was  effaced.  An  in- 
cision fifteen  centimeters  long  was  made  in  the  median  line, 
beginning  a  little  above  the  navel,  and  the  womb  was  quickly 
reached.  A  frightful  gush  of  blood  followed  the  cut  into  the 
uterus,  but  the  section  was  rapidly  completed,  and  a  living 
child  weighing  twenty -seven  hundred  grams  was  removed. 
The  placenta  was  then  extracted,  and  the  womb  was  drawn 
out  of  the  abdomen  by  means  of  two  cyst  forceps  which  had 
been  previously  applied  to  the  edges  of  the  uterine  wound. 
Two  pins  were  passed  through  the  lower  portion  of  the 
uterus,  an  iron  wire  was  put  around  below,  and  another 
between  them,  and  both  were  drawn  tight  with  the  ligateur 
Cintrat.  Then  the  body  of  the  uterus,  together  with  the 
ovaries  and  Fallopian  tubes,  was  removed.  The  stump  was 
touched  with  perchloride  of  iron  and  brought  between  the 
lips  of  the  abdominal  wound,  which  was  then  closed  with 
one  superficial  and  six  deep  sutures.  The  perfect  Lister 
dressing  was  applied.     The  operation  lasted  three  quarters  of 


SUCCESSFIJL   CASES.  161 

an  hour.  The  subsequent  history  of  the  case  was  very  sim- 
ple. On  the  evening  of  the  twenty-first,  the  highest  temper- 
ature, 38.9°  C,  was  reached.  By  the  twenty-eighth,  all  the 
stitches  had  been  removed,  and  then  the  pins  were  withdrawn. 
The  pedicle  disappeared  on  the  second  of  December,  and 
cicatrization  was  complete  on  the  twentieth.  In  about  six 
weeks  the  patient  was  completely  cured.  There  is  but 
slight  abdominal  protrusion,  the  cervix  is  large  and  movable, 
and  she  had  sexual  congress  without  accident  two  and  a  half 
months  after  the  operation.  In  direct  violation  of  orders, 
her  child,  when  three  days  old,  was  carried  from  her  cham- 
ber, the  temperature  of  which  was  23°  C,  to  a  very  cold 
church  to  be  baptized.  It  had  previously  been  particularly 
well ;  but  it  immediately  became  ill,  and  died  in  thirteen 
days. 

The  second  of  these  women  was  in  the  service  of  Professor 
Potain,  in  the  HOpital  Necker.  She  was  twenty-two  years 
old,  one  hundred  and  thirty  centimeters  high,  very  rachitic, 
with  a  sacro-pubic  diameter  of,  possibly,  five  centimeters. 
She  had  been  in  labor  thirty-six  hours,  and  the  amniotic 
fluid  had  been  discharged  twenty-four.  After  having  admin- 
istered chloroform  for  several  hours  to  quiet  her  extreme 
excitement,  I  performed  the  operation  at  nine  in  the  evening 
of  the  thirtieth  of  December,  1879.  The  os  was  dilated  to 
the  size  of  the  palm,  and  labor  was  in  full  progress.  I  began 
the  abdominal  incision  of  sixteen  centimeters  well  above  the 
navel,  and  ended  it  at  a  greater  distance  from  the  pubes 
than  in  the  preceding  case.  Considerable  hemorrhage  fol- 
lowed the  incision  into  the  uterus.  The  infant's  shoulder 
presented,  but  it  was  pushed  back,  and  the  child  was  ex- 
tracted by  the  feet.  It  proved  to  be  a  fine  boy,  weigh- 
ing more  than  three  kilograms,  and  immediately  breathed 
well.      The  treatment  of  the  wound  was  like  that  in  the 


162  ANTISEPTIC    STJKGEEY. 

previous  case.  During  the  subsequent  history  the  only, 
alarming  symptom  was  an  extraordinary  acceleration  of  the 
respiration  (fiftj^-five  a  minute)  twenty-four  hours  after  the 
operation.  The  temperature  never  reached  38°  C.  The 
wound  was  dressed  on  the  fifth  and  again  on  the  ninth  days, 
the  pedicle  dropping  out  of  sight  on  the  second  of  these 
occasions.  By  the  end  of  January,  1880,  there  remained 
only  a  very  superficial  ulceration.  She  began  to  get  up  in 
February,  and  has  now  been  well  for  a  long  time.  The  heal- 
ing was  so  perfect  that  but  little  trace  of  the  operation  re- 
mains. The  baby  was  confided  to  the  care  of  one  of  the 
nurses,  and  is  doing  well. 

The  other  two  operations  were  fatal.  One  was  performed 
at  the  Maternity  on  the  third  of  December.  The  woman 
died  in  thirty-six  hours  ;  the  child  still  survives. 

The  final  case  was  in  my  service  at  the  Cochin,  on  the 
seventeenth  of  January,  1880.  The  sacro-pubic  diameter 
was  forty-nine  millimeters.  At  first  the  patient  was  in  very 
good  condition ;  but  she  had  a  violent  nervous  attack  four 
hours  after  the  operation,  and  expired  in  twenty-three  hours. 
The  child  lived  three  days. 

I  believe  that  my  operations  demonstrate  the  desirability 
of  making  the  abdominal  incision  at  a  higher  point  than  has 
hitherto  been  practised ;  for,  by  keeping  the  wound  at  a  good 
distance  from  the  pubes,  perfect  asepsis  is  much  more  likely 
to  be  accomplished. 

If  great  attention  is  bestowed  upon  the  antiseptic  precau- 
tions it  is  not  necessary  to  have  a  special,  absolutely  pure 
apartment  for  the  operation.  One  of  my  patients  was  oper- 
ated on  and  recovered  in  a  badly  ventilated  chamber,  which 
had  been  sometimes  used  for  the  isolation  of  contagious  dis- 
eases. The  essentials  are  seclusion,  warmth,  quiet,  attention, 
incessant  antiseptic  precautions,  and  sufficient  comforts. 


ABDOMINAL   OPERATIONS.  163 

Hydatid  cysts  of  the  liver. 

The  opening  of  large  hydatid  cysts  of  the  liver  has  been 
done  by  Volkmann  in  the  following  manner :  he  incises  the 
abdominal  wall  as  far  as  the  liver,  and  then  applies  the  per- 
fect Lister  dressing.  Several  days  are  allowed  to  pass,  in 
which  a  slight  inflammation  excites  adhesion  between  the  liver 
and  the  abdominal  wall,  and  then  he  can  open  the  cyst  and 
treat  it  with  antiseptic  injections. 

A  similar  operation  has  been  made  in  the  case  of  a  cyst 
which  was  very  difficult  to  empty,  by  first  performing  resec- 
tion of  a  rib  overlying  the  liver,  and  then  opening  the  abscess 
at  another  time. 

Nephrotomy,  gastrotomy,  normal   ovariotomy,  splenotomy,  etc. 

I  merely  indicate  by  name  these  cases  of  antiseptic  ab- 
dominal surgery ;  practically,  the  precautions  which  should 
be  taken  do  not  differ  from  those  which  we  have  pointed  out 
in  the  before-mentioned  operations. 


CHAPTER    XX. 

Surgery  of  the  Female  Genital  Organs.  —  Operations  with 
Perfect  and  Imperfect  Asepsis.  —  Obliteration  of  the 
Vagina.  —  Vesico  -  vaginal  Fistula.  — Perineorrhaphy.  — 
Enucleation  of  Fibrous  Tumors  of  the  Uterus.  —  Aseptic 
Accouchement. 

It  is  a  matter  of  extreme  difficulty  to  obtain  perfect  asepsis 
in  the  neighborhood  of  the  anus,  vagina,  and  urethra  ;  but 
yet,  it  can  be  achieved  in  some  cases,  while  in  others  the 
attempt  will  be  unsuccessful.  Nevertheless,  by  following  the 
precepts  of  the  antiseptic  method,  the  surgical  interference  is 
much  simplified,  suppuration  is  diminished  or  repressed,  and 
septic  accidents  are  less  to  be  dreaded.  This  is  not  strictly 
Listerian  surgery,  and  yet  it  is  a  style  of  practice  which  is 
inspired  by  Lister's  teachings.  So,  without  going  into  minute 
details,  I  devote  this  chapter  to  enforcing  its  importance  upon 
the  mind  of  the  reader ;  the  special  applications  he  will  be 
able  to  make  for  himself.  I  will  begin  with  those  operations 
which  may  be  strictly  aseptic,  at  least  for  a  time,  and  follow 
with  those  which  are  only  partially  aseptic. 

Ohliterdtion  of  the  vagina. 

It  is  well  known  that  the  operation  of  opening  the  hymen, 
the  vagina,  and  the  uterus,  when  the  menstrual  fluid  has 
been  dammed  up  behind  an  obstruction  for  months  or  years, 
is  one  of  especial  gravity.  If  the  opening  is  made  without 
the  introduction  of  instruments  or  fluid  into  the  vagina,  pow- 


IMPEEFOEATE   VAGINA.  165 

erful  and  frequent  antiseptic  injections  diminish  this  gravity ; 
but  fatal  cases  are  unfortunately  still  common.  In  my  opin- 
ion, the  danger  depends  upon  the  immediate  accidents,  and  I 
think  that,  if  one  can  insure  complete  asepsis  during  the  first 
few  days,  and  the  uterus  has  once  been  restored  to  its  normal 
condition,  the  chance  of  accidents  is  only  moderate. 

The  plan  which  I  proposed  I  have  twice  tried  with  success. 
It  consists  in  carefully  cleansing  the  adjacent  parts,  making 
an  opening  with  all  the  precautions,  establishing  drainage, 
and  applying  masses  of  gauze  and  a  mackintosh.  The  bowels 
are  to  be  confined.  Twice  or  thrice  in  twenty-four  hours  a 
probe  is  passed  with  all  the  desirable  precautions,  including 
the  spray.  No  vaginal  injections  are  made.  After  five  or 
six  days,  when  the  womb  has  returned  to  its  normal  condi- 
tion, the  severity  of  treatment  may  be  relaxed,  if  the  woman 
cannot  endure  the  precautions  any  longer ;  but  if  one  can 
gain  a  few  days,  so  much  the  better.  Then  the  dressing  is 
continued  in  the  same  way,  but  the  patient  is  allowed  to 
urinate  and  go  to  stool.  But,  in  this  case,  vaginal  injections 
of  carbolized  water  are  demanded,  because  the  vaginal  dis- 
charge immediately  becomes  odorous. 

On  the  fourth  of  March,  1877, 1  operated  upon  a  girl  of  sev- 
enteen, whose  abdomen  had  been  growing  large  for  two  years. 
At  the  menstrual  periods  the  pain  was  intense.  The  lower 
end  of  the  vagina  was  about  three  centimeters  from  the  sur- 
face, as  was  determined  by  rectal  examination.  Tlie  fundus 
of  the  uterus  had  risen  up  as  high  as  the  navel.  At  the  time 
of  the  operation,  there  escaped  a  full  wash-bowl  of  altered, 
tarry  blood,  and  the  discharge  continued  extremely  abundant 
for  the  three  following  days  ;  but,  with  the  precautions  men- 
tioned, the  liquid  remained  absolutely  odorless.  Thus  it 
continued  up  to  the  fifth  day,  when,  the  uterus  having  re- 
sumed its  natural  size,  the  discharge  was  insignificant.     The 


166  ANTISEPTIC    SUEGERY. 

strictness  of  the  watch  was  abated,  and  from  the  next  day 
the  hqviid  had  an  odor.  Abundant  vagmal  injections  were 
then  given  twice  a  day  with  two-and-a-half  per  cent,  carbohe 
solution,  and  the  patient  was  well  in  three  weeks,  without 
having  had  any  inflammatory  complication.  The  menses 
were  regularly  established,  and  this  young  woman,  who  was 
married  in  November,  1878,  was  delivered  without  difficulty 
of  a  beautiful  child  on  the  twenty-fourth  of  September,  1879. 

In  another  case,  the  blood  found  an  exit  beside  one  of  the 
labia  majora,  a  little  before  the  hour  fixed  for  the  operation. 
Nevertheless,  I  was  able  to  apply  an  antiseptic  dressing, 
and  the  first  days  passed  as  in  the  first  case,  without  bad 
odor,  without  putrefaction  of  the  confined  fluid.  At  last,  on 
the  fifth  day,  I  stopped  passing  the  probe,  and  on  the  mor- 
row the  discharge  began  to  smell.  The  artificial  opening 
was  enlarged  by  an  incision,  and  the  patient  recovered.  For 
more  than  a  year  her  catamenia  have  been  regular. 

In  such  cases,  the  following  method  should  be  pursued: 
all  the  folds  of  the  vulva,  the  parts  covered  with  hair,  and  the 
entire  anal  region  must  be  scrupulously  cleansed  with  washes 
of  strong  carbolic  solution  ;  under  the  spray,  a  free  incision 
is  to  be  made,  as  in  the  case  of  my  first  patient;  the  uterus 
is  to  be  gently  pressed,  so  that  the  blood  will  slowly  drain 
away,  and  two  large  tubes  are  inserted  side  by  side  ;  the 
gauze  dressing  should  then  be  applied  directly  to  the  vulva, 
without  the  intervention  of  the  protective.  The  mass  should 
be  thick,  and,  at  the  anus,  should  make  a  kind  of  barrier  to 
divert  the  intestinal  gas.  Above  the  gauze  the  mackintosh 
is  placed.  The  dressing  needs  to  be  often  changed,  for,  in 
the  first  hours,  it  gets  saturated  with  the  fluid  and  easily 
becomes  infected.  It  is  a  good  plan  to  bathe  the  parts  in 
strong  solution  at  each  dressing,  but  not  to  make  injections. 
It  should  be  remembered  that  the  skin  is  more  delicate  in 


VAGINAL  OPEEATIONS.  167 

some  individuals  than  in  others,  and,  in  any  event,  rubbing 
with  cloths  wet  in  strong  carbolized  water  should  be  avoided. 


Vesico-vaginal  fistula  and  ruptured  perineum. 

In  other  operations  upon  the  external  genitals  we  have  not 
the  means  of  sheltering  the  parts  as  completely  from  germs 
as  in  the  case  of  occluded  vagina.  Such  are  those  for  vesico- 
vaginal fistula  and  ruptured  perineum. 

Great  care  should  always  be  taken  in  the  preliminary 
washings  with  carbolic  water.  It  is  well,  before  taking  the 
sutures,  to  touch  with  the  strong  solution  the  surfaces  which 
are  to  be  brought  together.  There  is  advantage  in  employ- 
ing the  antiseptic  gauze  and  protective  to  afford  complete 
and  permanent  protection  to  the  wound.  Boracic  acid  lint 
is  very  convenient  material  to  form  a  kind  of  tampon  for  the 
vagina  and  its  neighborhood ;  but,  in  all  these  cases,  the  anti- 
sepsis will  be  only  relative. 

Catgut  has  been  a  good  deal  employed  both  for  vesico- 
vaginal-fistula  operations  and  for  perineorrhaphy.  In  the 
fistula  cases  its  application  is  very  easy,  and  we  have  the  im- 
mense advantage  of  not  being  obhged  to  withdraw  the 
thread.  To  make  this  suture  conveniently,  we  should  have 
catgut  which  is  at  once  flexible,  fine,  and  solid,  as  the  most 
of  the  material  in  the  market  is  not. 

In  perineorrhaphy  there  is  no  especial  advantage  in  the  use 
of  the  catgut,  except  for  the  stitches  which  we  take  in  the 
vagina,  where  they  are  absorbed  without  giving  us  any  con- 
cern. Dr.  Auguste  Eeverdin  has  reported  two  entirely  suc- 
cessful cases,  made  five  days  after  accouchement.  He  let  the 
stitches  take  care  of  themselves.  In  one  of  the  cases,  four 
catgut  sutures  were  taken  in  the  vagina  and  five  in  the 
perineum.  In  spite  of  the  most  unfavorable  circumstances, 
the  union  was  complete. 


168  ANTISEPTIC    SURGERY. 

The  ingenuity  of  the  surgeon  ought  to  inspire  him  to  apply 
the  antiseptic  method  in  these  cases  in  such  a  manner  as  not 
to  produce  irritation  or  to  injure  the  sutures. 

Enucleation  of  fibrous  tumors  of  the  uterus. 

Operations  for  the  removal  of  fibrous  tumors  of  the  womb 
are  rarely  followed  by  serious  consequences.  It  would  al- 
ways be  desirable  to  diminish  the  chances  of  peripheral  in- 
flammation, and  to  reduce  the  more  or  less  fetid  discharges 
which  follow  the  operation. 

The  method  which  I  recommend  and  have  successfully 
employed  is  as  follows :  the  vagina  is  washed  with  the 
weak  carbolized  solution,  or  the  strong,  if  it  can  be  borne  ; 
after  the  operation,  which  is  performed  in  any  way  the  sur- 
geon may  prefer,  the  vagina  is  again  washed  out  with  an 
abundant  injection  of  the  strong  solution  ;  then  there  is  placed 
upon  the  vulva  a  large  compress,  saturated  with  weak  car- 
bolic water,  and  this  should  be  frequently  renewed.  Instead 
of  this  compress,  a  generous  parcel  of  antiseptic  gauze  may 
be  used. 

In  removing  fibrous  tumors  from  the  womb,  whether  they 
are  pediculated  or  not,  I  prefer  the  method  of  enucleation. 
I  could  cite  three  operations  of  this  kind,  in  which  antiseptic 
precautions  were  adopted.  The  first  two  were  in  the  ser- 
vice of  M.  Siredey,  and  one  of  the  tumors  was  intra-mural. 
The  vaginal  injections  were  made  with  the  weak  solution. 
Both  patients  recovered  without  accident.  The  third  I 
operated  on  in  this  city,  with  the  assistance  of  Dr.  Barborin, 
of  Joinville.  The  discharge  was  extremely  fetid  before  the 
operation.  The  strong  solution  was  used  for  the  injection, 
and  the  dressings  were  made  as  I  have  advised  above.  The 
odor  disappeared  almost  immediately,  and  the  recovery  was 
very  rapid. 


LISTERIAS  MIDWIFERY.  169 

I  ought  to  add  that,  in  all  operations  which  I  make  at  the 
upper  part  of  the  vagina,  even  simple  scarifications  of  the 
neck,  I  use  carbolized  injections.  As  a  complement  to  these, 
V7e  may  employ  antiseptic  tampons ;  but,  as  they  are  liable 
to  excite  irritation  in  wounds  of  the  cervix,  I  usually  con- 
tent myself  with  vulvar  compresses,  even  after  serious  opera- 
tions. 

Aseptic  accouchement. 

If  there  is  any  traumatic  condition  in  which  asepsis  would 
seem  to  be  more  desirable  than  in  any  other,  it  is  evidently 
parturition ;  and  it  is  plainly  a  matter  of  duty  to  endeavor  to 
afford  protection  in  this  state  by  the  antiseptic  method.  Un- 
fortunately, those  who  have  made  the  trial  seem  to  have 
taken  into  consideration  only  the  infectious  element  in  the 
development  of  puerperal  accidents ;  and  have  not  thought 
of  the  harm  which  may  come  from  traumatic  injuries  and 
untimely  contact.  I  confess  that  I  have  no  confidence  in 
constantly  repeated  vaginal  and  even  uterine  injections,  or  in 
the  antiseptic  plugging  of  the  vagina ;  and  I  have  a  partic- 
ularly poor  opinion  of  injections  in  the  days  immediately 
following  delivery. 

So,  after  having  made  various  experiments  and  seen  the 
very  mediocre  results  of  these  violent  efforts,  I  have  come  to 
the  conclusion  that,  in  parturition,  the  antiseptic  surgeon 
should  be  satisfied  with  one  thing,  and  that  is  absolute  sur- 
gical cleanliness. 

Here  are  the  rules  which  I  have  followed  for  nearly  two 
years  in  my  service  in  the  Cochin  Hospital.  Not  only  is 
every  medical  officer  required  to  keep  his  hands  clean,  but,, 
in  addition  to  this,  he  is  strictly  forbidden  to  make  a  vaginal 
examination  of  a  woman,  or  to  pass  from  one  examination  to 
another,  without  washing  his  hands  in  the  weak  solution. 

12 


170  ANTISEPTIC    SUEGEEY. 

The  only  lubricant  employed  is  five-  or  ten-per-cent.  car- 
bolized  oil.  After  delivery,  the  vulva  is  washed  with  the 
weak  solution,  or,  if  the  case  requires,  with  the  strong,  and 
is  then  dressed  with  a  compress  saturated  with  the  weak 
solution.  If  the  vulva  or  vagina  has  suffered  any  serious 
injury,  the  wound  is  washed  with  the  strong  solution.  Im- 
mediately before  operations,  the  vulva  and  the  surrounding 
parts  are  bathed  in  the  same.  After  serious  operations,  which 
have  necessitated  the  introduction  of  instruments  or  hands 
into  the  vagina  or  uterus,  I  generally  inject  the  vagina  or 
even  the  womb  with  the  two-and-a-half-per-cent.  solution, 
once  or  several  times  in  succession,  taking  great  care  that  all 
the  fluid  returns.  Sometimes  I  have  used  the  strong  solution 
in  such  cases. 

Last  year  I  performed  version  in  a  case  of  shoulder  presen- 
tation, occurring  in  the  service  of  M.  Siredey.  The  foetus 
was  distended  with  gas  like  a  balloon,  and  I  practised  evis- 
ceration. The  womb  was  enormously  distended  with  gas 
and  fetid  liquids,  and  there  seemed  to  be  but  small  chance 
for  the  woman's  surviving  the  operation.  I  rinsed  out  the 
uterine  cavity  with  the  weak  solution  several  times.  The 
patient  recovered  without  any  difficulty. 

The  question  arises  as  to  whether  antiseptic  precautions 
can  be  pushed  any  further.  The  spray  would  seem  to  have 
some  power  in  purifying  the  atmosphere  of  the  ward,  but  it 
is  not  necessary.  However,  I  have  used  it  in  wards  where 
I  had  other  patients. 

Injections  made  daily  or  every  other  day  have  been  greatly 
extolled ;  but,  according  to  my  experience,  they  may  be  pro- 
ductive of  fatal  irritation,  and  I  prohibit  their  employment  in 
my  service,  except  in  very  rare  cases. 

Finally,  there  is  a  very  curious  fact.  In  the  great  majority 
of  cases  the  lochia  are  fetid ;  but  all  that  is  needed  to  abolish 


RESULTS   IN   OBSTETRICS.  171 

this  odor  is  to  carefully  wash  the  vulva  with  carbolic  water, 
and  to  keep  its  opening  constantly  covered  with  a  moist,  car- 
bolized  compress  or  with  antiseptic  gauze.  Almost  invariably 
it  is  the  contact  of  the  air  that  makes  the  lochia  offensive  — 
a  very  interesting  fact  in  its  bearing  upon  the  putrefaction  of 
secretions  at  the  natural  orifices. 

If  I  have  to  use  tampons,  I  employ  only  those  that  are 
thoroughly  carbolized.  I  often  practise  a  sort  of  incomplete 
plugging  after  labor,  and  I  have  never  seen  any  unfavorable 
results  from  it. 

The  employment  of  these  means  has  given  me  excellent 
results.  At  the  Cochin  Hospital  in  18T8,  there  were  seven 
hundred  and  seventy  deliveries,  serious  operations  being  per- 
formed in  a  good  number  of  them.  There  were  five  deaths, 
of  which  only  two  were  on  account  of  puerperal  diseases,  the 
other  three  comprising  a  consumptive,  who  was  admitted  in 
the  very  last  stages,  and  died  twenty-one  hours  after  her 
accouchement ;  a  patient  who  came  from  the  medical  service 
with  acute  pericarditis,  and  lived  only  four  hours;  and  a 
woman  in  convulsions,  who  expired  two  hours  after  entering. 
Result :  not  a  death  from  operation ;  gross  mortality,  0.694 
per  cent.  ;  puerperal  mortality,  0.232  per  cent. 

The  most  remarkable  circumstance  about  all  this  is  that  I 
had  my  students  examine  all  the  women  in  labor  and  all  the 
subjects  of  operation  every  morning,  and  I  made  them  prac- 
tise the  vaginal  touch  during  the  operations  ;  and  yet  the 
mortality  of  the  patients  on  whom  I  operated  was  lower  than 
that  of  women  in  ordinary  confinement. 

My  results  in  1879  have  not  been  as  good.  In  the  first 
place,  the  report  is  damaged  by  some  cases  of  women  who 
were  brought  to  the  hospital  in  a  moribund  condition ;  but, 
besides  these,  there  were  some  deaths  which,  in  my  opinion, 
might  have  been  prevented  if  the  method  had  been  practised 
with  sufficient  rigor. 


172  ANTISEPTIC    SUEGBRY. 

Up  to  to-day,  the  twentieth  of  November,  the  confinements 
number  six  hundred  and  eightj'^-five.  Eleven  deaths  have 
occurred,  giving  an  apparent  mortality  of  1.60  per  cent.  But 
it  would  be  unjust  to  the  hospital  to  charge  the  following 
deaths  to  its  discredit :  three  women  brought  in  with  rupture 
of  the  uterus,  who  were  promptly  delivered  by  craniotomy, 
embryotomy,  and  the  ajDplication  of  the  forceps  respectively  ; 
one  woman,  dying  in  eclampsia  when  she  was  admitted  ;  and 
one  consumptive,  with  pulmonary  lesions,  tuberculous  peri- 
tonitis, etc.,  which  speedily  killed  her.  In  reality,  there  have 
been  but  six  deaths  due  to  accouchement  among  the  patients 
who  were  treated,  and  this  reduces  the  mortality  to  0.89  per 
cent. 

Moreover,  in  the  six  there  were  two  vicious  insertions  of 
the  placenta,  cases  exceptionally  bad  in  spite  of  the  medium. 
These  women,  admitted  in  wretched  condition,  exhausted 
with  bleeding,  were  unable  to  rally,  and  rapidly  succumbed 
after  delivery. 

The  actual  mortality,  therefore,  of  the  institution  is  four, 
or  0.58  per  cent. — three  women  delivered  naturally  and  one 
with  instruments. 

These  two  years  have  presented  a  considerable  number  of 
difficult  cases.  In  1879  alone  there  were  five  vicious  inser- 
tions of  the  placenta,  cases  of  eclampsia,  and  other  complica- 
tions of  pregnancy. 

The  operations  performed  in  these  years  were  as  follows  :  — 

Application  of  the  forceps,  sixty-two,  without  a  death ; 
besides  one  in  the  case  of  a  woman  brought  in  from  the  city, 
with  a  rent  in  the  womb,  who  died  shortly  after. 

Version,  fifteen. 

Operation  on  account  of  abnormal  attachment  of  the  pla- 
centa, one  ;  the  patient  died. 

Induced  labor,  eight ;  no  deaths. 


DIMINISHED  MORTALITY.  173 

Artificial  delivery,  eleven ;  one  death  from  puerperal  ac- 
cidents. 

Cephalotripsy,  four ;  no  death.  In  one  other  case  there 
vras  evident  rupture  of  the  uterus,  and  the  child's  head  was 
crushed  to  facilitate  delivery ;  the  patient  died  two  hours 
afterward. 

Embryotomy,  one ;  cured.  One  other  embryotomy  was 
performed  to  deliver  a  woman  who  was  dying  from  rupture 
of  the  womb,  and  who  survived  the  operation  but  one  hour. 

Thus,  leaving  out  the  artificial  deliveries,  the  mortality 
from  traumatism  is  really  nothing,  and  consequently  less  than 
in  the  normal  confinements ;  and  yet  there  were  ninety-one 
cases  —  certainly  a  respectable  number. 

In  passing,  I  wish  to  call  attention  to  the  three  cases  of 
rupture  of  the  uterus,  brought  in  from  the  city,  and  to  the 
case  of  convulsions,  almost  dead  when  admitted.  They  give 
us  an  idea  of  the  numerous  ways  in  which  the  obstetrical 
mortality  of  the  city  is  falsely  represented  at  the  expense  of 
the  reputation  of  the  hospitals  —  a  subject  upon  which  I 
shall  have  something  further  to  say  at  the  proper  time  and 
place. 

Certainly,  we  must  consider  it  a  fine  result  to  have  re- 
duced the  puerperal  mortality  to  a  point  where  there  are  but 
six  deaths  in  one  thousand  four  hundred  and  fifty-five  cases, 
or,  in  other  words,  about  0.41  per  cent.  For  my  part,  I  de- 
clare myself  satisfied  with  this  result  for  a  beginning,  and  for 
the  further  reason  that  I  am  able  to  give  a  large  amount  of 
instruction  without  danger  ;  but  I  am  of  opinion  that  much 
better  results  can  be  obtained.  In  my  service  I  achieved 
much  less  than  I  sought.  A  crowd  of  details  still  escape  me, 
eluding  my  vigilance.  I  have  an  absolute  conviction  that,  of 
the  three  deaths  which  occurred  this  year,  at  least  two  could 
have  been  avoided,  although  I  cannot  say  precisely  in  what 


17.4  ANTISEPTIC    SURGEEY. 

respect  we  were  at  fault.  It  is  impossible  to  give  the  reader 
in  detail  all  the  desiderata  which  I  observe.  And  yet,  the 
attainment  of  the  same  results  elsewhere  requires  the  abso- 
lute reform  of  the  habits  of  the  chiefs  ©f  the  services,  of  the 
administrative  officers,  and  of  the  students.  In  lying-in 
wometi  more  than  in  any  other  wounded  patients  is  it  indis- 
pensable to  apply  the  antiseptic  principle  everywhere. 

I  regret  to  see  large  sums  of  money  devoted  to  the  estab- 
lishment of  hospitals  which  are  not  really  needed.  Improve- 
ments can  be  made.  With  sufficient  room  and  antiseptic 
cleanliness,  the  condition  of  the  old  and  bad  institutions  can 
be  immensely  ameliorated,  and  it  can  be  made  even  perfect 
without  any  great  expenditure  in  newly  invented  luxuries. 
M.  Tarnier's  pavilion  at  the  Paris  Maternity  shows  how  new 
structures  can  be  built.  For  my  part,  I  believe  in  still  greater 
simplicity,  and  that  there  are  serious  inconveniences  in  rigor- 
ous isolation  ;  and  I  am  of  opinion  that  there  are  many  local- 
ities which  can  be  made  very  useful  by  attending  to  the 
following  conditions :  — 

Abolish  pure  water  in  the  lying-in  service,  and  abandon 
the  use  of  all  germ-bearing  epithems ;  disinfect  all  the  linen 
with  heat,  disinfect  everything  extemporaneously  with  ear- 
bolized  water ;  do  not  disturb  the  genitals  of  the  woman, 
even  with  antiseptic  intent ;  insure  her  repose ;  supply  her 
with  sufficient  nourishment ;  keep  her  quiet  at  the  last  of  her 
gestation ;  exact  antisepsis  of  everybody  who  comes  near  the 
patient. 

A  thousand  useless  precautions  are  taken,  and  this  is  neg- 
lected. If  an  interne  understands  sufficiently  how  to  make 
himself  clean,  he  can  devote  himself  to  all  his  occupations, 
make  the  post-mortem  examinations  which  are  a  part  of  his 
duty,  dissect,  and  examine  patients  without  danger.  If  he  is 
neglectful  of  antiseptic  precautions,  it  will  be  best  to  quaran- 


A   PLEA  FOR   CLEANLINESS,  175 

tine  him,  or  else  he  will  always  be  coming  in  and  poisoning 
the  lying-in  patients.  The  kind  who  never  make  a  necropsy 
often  kill  a  great  many  more  peoj)le  than  the  anatomists  who 
are  careful  about  antiseptic  precautions. 

In  Paris,  all  the  habits  of  the  students  are  in  need  of 
reform.  I  do  not  blame  them  ;  it  is  physically  impossible  for 
them  to  be  surgically  neat  in  the  hospital.  Reforms  are 
demanded  in  the  interest  of  the  patients  and  in  the  interest 
of  instruction,  which  ought  to  be  made  compatible  with  the 
safety  of  the  sick.  Hardly  more  than  a  single  word  is  needed 
to  indicate  these  reforms.  At  present,  not  only  is  nobody 
compelled  to  wash  his  hands,  but  it  is  almost  impossible  to  do 
it  in  a  hospital,  so  poor  are  the  facilities. 

A  liberal  and  intelligent  administration,  anxious  to  comply 
with  the  wishes  of  the  surgeons,  has  made  it  easy  for  us  now- 
a-days  to  practise  antiseptic  surgery  in  the  hospitals  of  Paris ; 
but  we  do  not  think  the  government  inclined  to  favor  in 
every  way  the  practice  of  antiseptic  midwifery. 


CHAPTER    XXL 

The   Ligation    of  Vessels.  —  Arteries   and  Veins.  —  Radical 
Cure  of  Varix.  —  Varicocele. 

The  ligation  of  vessels  appears  in  an  entirely  new  light: 
there  is  no  elimination  of  a  foreign  body,  no  necessary  division 
of  an  obliterated  "vessel,  no  irritation  of  the  denuded  trunk. 
At  the  very  outset  one  can  see  what  modifications  this  in- 
volves in  our  method  of  treatment. 

In  the  case  of  ligatures  designed  to  close  gaping  vessels  in 
a  wound,  we  put  in  our  sutures  without  any  anxiety  as  to  the 
thread  which  remains  behind.  No  argument  is  necessary  to 
prove  the  immense  superiority  of  this  procedure  over  all  that 
have  been  proposed  to  replace  the  ligature  —  torsion,  forci- 
pressure,  acupressure  —  even  if  we  look  merely  at  the  security 
obtained.  So  remarkable  is  the  special  peculiarity  of  the  car- 
bolized  catgut  that  it  can  maintain  itself  even  in  a  wound 
which  is  not  dressed  antiseptically,  although  this  is  not  con- 
stant. In  my  first  edition  I  reported  the  experience  of  Keith, 
who  employed  it  in  ovariotomy  without  the  antiseptic  method, 
and  of  Oliver  Pemberton,  who  used  it  to  ligate  the  femoral 
without  the  Lister  dressing. 

The  ligature  of  vessels  in  their  continuity,  made  with  all 
the  rigor  of  antiseptic  surgery,  may  be  especially  quoted  as 
giving  results  of  the  most  valuable  character.  On  this  point 
Lister  draws  his  convictions  from  his  experience,  which  is 
already  very  extensive.  The  wound  closes  over  the  knot  of 
catgut,  which  does  not  cut  the  artery.  Obliteration  of  the 
artery  takes  place  without  division.     The   catgut  supports 


CATGUT   FOE  LIGATUEES.  177 

the  vessel,  at  least  in  the  first  days,  and  until  it  is  absorbed. 
These  facts  render  it  probable  that  we  shall  be  able  to  tie 
successfully  the  great  vessels,  whose  division  so  uniformly 
induces  secondary  hemorrhage.  It  is  also  likely,  as  certain 
observations  of  Lister  and  his  followers  seem  to  show,  that 
an  artery,  the  femoral,  for  example,  may  be  safely  tied  close 
to  a  large  branch.  As  the  artery  is  not  divided,  secondary 
hemorrhage  will  not  ensue. 

In  this  class  of  operations  antiseptic  surgery  requires 
nothing  more  than  ordinarily.  Nevertheless,  it  is  well  to 
recommend  the  use  of  catgut  of  large  size  and  tested  strength. 
I  have  seen  reports  of  accidents,  which  seemed  to  me  to  be 
caused  by  the  poor  quality  of  the  material.  There  is  so  much 
bad  catgut  in  the  market  that  I  insist  upon  the  importance  of 
this  direction.     The  older  the  thread  is,  the  better  it  is. 

It  has  been  objected  to  the  catgut  ligature  that  the  thread 
rapidly  breaks  down,  but  I  have  never  comprehended  the 
force  of  the  objection.  To  give  way  at  the  moment  when 
the  ordinary  thread  begins  to  cut  the  tissues  could  not  seri- 
ously be  considered  as  supporting  them,  and  that  proisess  be- 
gins almost  immediately  after  the  application  of  the  ligature. 

The  catgut  divides  the  inner  coats  of  the  artery  exactly  as 
the  silk  does,  and  repair  takes  place  just  as  it  does  when  the 
silk  injures  the  external  tunic,  that  is  to  say,  when  the  silk 
does  not  leave  a  part  of  the  vessel  intact  to  sustain  the  inner 
tunics  which  have  been  cut.  What  does  it  matter  if  there  is 
a  giving  way  when  the  thread  is  absorbed?  After  forty- 
eight  hours  there  is  no  chance  of  hemorrhage  in  the  wound. 
Some  experiments  upon  animals  have  convinced  me  of  the 
identity  of  the  mode  of  repair  of  vessels. 

Nobody  at  the  present  time  questions  the  importance  of 
ligation  of  arteries  in  their  continuity ;  it  has  been  performed 
successfully  a  great  many  times  upon  almost  all  the  large 


178  ANTISEPTIC    SURGERY. 

vessels.  Of  course,  it  will  be  understood  that  the  general 
principles  of  drainage  and  of  suturing  will  guide  us  in  the 
after-treatment  of  these  cases. 


The  radical  cure  of  varix. 

Although  formerly  we  hesitated  to  apply  ligatures  to  veins, 
at  the  present  time  we  can  do  it  with  perfect  safety,  as  the 
thread  excites  no  inflammation,  no  suppuration  around  it. 

Lister  reports  a  case  in  which  he  sutured  the  lips  of  a 
gaping  wound  of  the  axillary  artery  with  very  fine  catgut. 
It  is  much  simpler  and  more  common  to  tie  the  entire  vessel. 
This  method  has  made  great  progress  possible  in  the  surgery 
of  veins.  Confident  of  this,  I  have  employed  simple  ligation 
as  a  means  of  radically  curing  varicose  veins,  making  my  first 
operation  in  the  early  part  of  1876. 

The  method  of  procedure  is  as  follows :  the  large  venous 
trunk  is  freely,  though  not  extensively,  uncovered,  and  a 
sufficiently  strong  thread  of  catgut  is  passed  under  it.  A 
double  knot  is  then  tied  with  moderate  tightness,  and  the 
ends  of  the  thread  cut  short.  One  or  two  points  of  silver 
suture  are  taken  in  the  skin,  a  small  rubber  tube  being  in- 
serted through  an  orifice  left  in  the  most  dependent  portion 
of  the  wound,  which  is  then  dressed  in  the  usual  manner. 

This  operation  has  suggested  itself  to  several  surgeons. 
Schede  performed  it  after  me,  adding  the  division  of  the  vein 
between  two  ligatures.  Risel,  of  Halle,  tied  in  two  places, 
and  excised  the  intervening  portion  of  the  vessel.  Annan- 
dale  published  in  1879  the  report  of  a  case  in  which  he 
removed  from  the  left  leg  of  a  young  man  an  enormous  mass 
of  varicose  veins,  measuring  forty  centimeters  in  length, 
twenty-five  in  breadth,  and  fifteen  in  height.  His  patient 
made  a  perfect  recovery,  and  was  still  well  four  months  after- 
wards. 


VARICOSE  VEINS.  179 

This  excision  may  be  treated  with  drainage  or  with  com- 
plete closure,  according  to  the  extent  and  situation  of  the 
wound. 

Annandale  has  practised  ligation  of  veins  for  a  lono-  time. 
He  reported  a  case  of  varicocele  treated  in  this  way  as  early 
as  18T4. 

This  new  application  of  old  methods,  now  revived  with 
modern  security,  can  be  utilized  in  a  great  many  cases,  by 
following  out  the  general  indications. 


CHAPTER   XXII. 

The  Treatment  of  Abscesses. 

Acute  abscesses. 

The  treatment  of  abscess  is  certainly  one  of  the  most  curious 
applications  of  the  Lister  method,  for  it  is  very  remarkable  to 
see  the  cavity  of  an  abscess,  even  though  it  be  very  large, 
stop  suppurating  the  moment  it  is  opened,  and  close,  as  one 
may  say,  by  first  intention,  so  rapidly  does  the  adhesion  of 
its  walls  take  place. 

The  openings  into  an  acute  abscess  need  not  be  nearly  as 
extensive  as  by  the  ordinary  method ;  but,  if  the  patient  is 
anaesthetized,  I  prefer  a  large  incision,  which  I  afterwards 
reduce  by  taking  two  or  three  stitches. 

After  the  evacuation  of  the  pus,  it  is  useless  to  make  an 
injection,  if  the  cavity  is  small ;  but  if  it  is  very  large,  it  is 
necessary  to  throw  into  the  cavity  some  carbolized  water, 
strong  or  weak,  according  to  the  region  involved,  and  to 
cleanse  it  very  carefully.  Then  the  stitches  are  taken,  one 
or  two  drains  put  in  upright,  and  the  dressing  is  applied  in 
such  a  way  as  to  moderately  compress  the  walls  of  the  cav- 
ity.    If  the  discharge  is  abundant,  the  protective  is  useless. 

The  suppression  of  the  purulent  discharge,  which  is  fol- 
lowed by  one  of  a  sero-purulent  character,  is  a  surprise  at  the 
first;  but  the  rapidity  of  the  healing  is  much  more  aston- 
ishing. 

I  have  now  practised  this  procedure  more  times  than  I  can 
enumerate ;   but  I  can  cite  some  large  abscesses  which  have 


ANTHRAX.  181 

healed  up  with  amazing  speed.  I  cured  in  this  way,  in  ex- 
actly eight  days,  a  huge  abscess  in  the  sheath  of  the  right 
carotid  of  a  young  man.  In  the  service  of  M.  Millard,  at 
Beaujon,  two  years  ago,  I  opened  a  large  perinephritic  ab- 
scess in  a  young  woman.  It  was  a  phlegmon,  with  its  point 
of  departure  in  a  uterine  lesion,  the  causation  of  which  I  made 
out  by  the  assistance  of  my  researches  upon  the  lymphatics  of 
the  womb.  This  patient,  confided  to  the  care  of  Dr.  Tapret, 
then  the  interne  on  duty,  was  cured  in  eight  days  and  with 
three  dressings.  At  the  Lariboisi^re  I  opened  by  a  simple 
puncture  an  enormous  abscess  in  the  axilla  of  a  young  man, 
and  ten  days  after  there  was  not  a  trace  of  suppuration. 

When  abscesses  are  small,  the  cure  is  effected  much  more 
rapidly,  and  in  regions  where  the  scars  are  not  covered  by 
the  clothing,  this  is  a  very  important  fact.  In  regions  like 
the  breast,  where  the  abscess  is  the  point  from  which  new 
inflammations  push  out  in  every  direction,  we  are  much  less 
likely  to  have  a  series  of  abscesses.  The  secondary  purulent 
sinuses  disappear.  Cicatrices  on  the  borders  of  great  ab- 
scesses no  longer  come  to  weaken  people  whom,  otherwise, 
months  of  suppuration  condemn  to  suffer  permanent  retrac- 
tions. 

This  result  is  particularly  noticeable  in  whitlows  and 
phlegmons  in  the  palm  of  the  hand.  In  these  cases  it  is  well, 
after  having  freely  opened  the  abscess,  to  wash  it  thoroughly 
with  the  strong  solution.  As  the  parts  have  generally  been 
covered  previously  with  cataplasms,  it  is  necessary  to  take  ex- 
traordinary care  in  the  bathing  which  precedes  the  operation. 

The  same  remarks  will  apply  to  the  treatment  of  anthrax. 
As  regards  the  pain,  for  the  relief  of  which  it  is  usual  to 
recommend  the  heat  of  a  cataplasm,  a  hypodermic  dose  of 
morphine  will  soothe  it  more  completely  and  constitute  a 
desirable  substitute  for  the  common  epithem. 


182  ANTISEPTIC    SURGERY. 

Finally,  I  insist  upon  this  fact :  it  may  be  useful,  after  the 
incision  is  made,  to  inject  the  cavity  in  order  to  completely 
empty  it  of  pus  ;  but  this  should  by  no  means  be  repeated 
afterwards,  as  it  will  retard  the  healing  process. 

In  some  cases,  where  the  pouch  is  infected  anteriorly, 
where  it  has  been  impossible  to  maintain  the  aseptic  condi- 
tion, copious  washings  of  the  cavity  with  carbolized  water 
are  required.  The  necessity  of  thoroughly  evacuating  the 
injected  fluid  must  never  be  forgotten.  It  is  almost  always 
in  cases  of  large  pelvic  or  perirectal  abscesses  that  poisoning 
occurs.  I  have  seen  a  pelvic  abscess  the  injection  of  which 
gave  rise  to  slight  toxic  symptoms.  There  was  need  of  a 
counter-opening,  which  being  made,  the  injections  were  con- 
tinued without  further  difficulty. 

Where  there  is  intolerance  of  carbolic  acid,  a  weak  solution 
of  chloride  of  zinc  is  of  great  service. 

Cold  abscesses. 

In  these,  the  modification  in  the  walls  requires  to  be  more 
complete,  and  it  is  well  either  to  inject  the  cavity  with  an 
,eight-per-cent.  solution  of  chloride  of  zinc,  or  to  scrape  the 
inner  surface  with  the  curette  of  Volkmann.  I  have  had 
HOod  success  with  both  methods. 


Congestive  abscesses. 

The  treatment  of  these  is  certainly  one  of  the  most  difficult 
applications  of  the  antiseptic  method,  but  it  is  also  one  of  the 
most  valuable.  Up  to  the  present  time  they  have  been  7ioli 
me  tangere,  and  the  surgeon  has  approached  them  only  with 
extreme  repugnance. 

If  they  are  opened  antiseptically  the  first  result  is  that  the 


TREATMENT   OF   ABSCESS.  183 

evacuation  of  the  fluid  is  not  followed  by  inflammation  of  the 
pouch.  A  serous  matter  continues  to  be  discharged.  If 
the  dressing  is  kept  on  a  long  time,  the  cavity  is  finally  re- 
duced to  a  narrow  fistula,  and  the  primary  lesion,  after  elimi- 
nation of  the  sequestra,  may  heal  spontaneously.  The  opening 
should  be  sufiicient  for  very  easy  drainage  and  for  the  passage 
of  a  tube.  In  cases  of  migratory  abscesses  which  have  started 
from  a  distant  point,  as  the  vertebral  column,  it  is  better  to 
simply  open  them  without  washing  them  out.  Where  the 
original  seat  is  less  remote,  and  the  pouch  is  but  moderately 
large,  the  injection  of  carbolized  water  on  the  first  day  may 
be  advantageous.  Lister  quite  generally  puts  in  a  horsehair 
drain  in  these  cases. 

As  the  treatment  is  long,  it  is  necessary  to  carefully  avoid 
making  the  opening  in  the  neighborhood  of  any  source  of 
putrefaction,  such  as  any  open  suppuration  or  a  natural  cav- 
ity. If  this  condition  cannot  be  fulfilled,  it  will  be  wiser  to 
defer  the  opening  a  while. 

The  result  of  the  operation  in  this  class  of  cases  is  that  the 
cavity  is  reduced  in  size  and  the  walls  to  some  extent  adhere 
to  each  other.  If  the  abscess  depends  upon  extensive  bony 
lesions,  the  sequestra  will  be  thrown  off,  and  the  healing  will 
take  place  slowly,  without  fever,  without  any  surgical  com- 
plication. When  the  osseous  disease  is  accessible,  the  incision 
of  the  abscess  will,  of  course,  be  followed  by  the  operation 
which  is  necessary  for  a  cure.  If  the  involvement  is  only 
superficial  or  periosteal,  affairs  progress  more  rapidly. 

The  treatment  of  these  abscesses  requires  extreme  exactness 
in  the  application  of  the  dressing ;  for,  if  there  is  any  lapse, 
the  healing  will  be  retarded  not  a  little,  and  often  the  termi- 
nation may  be  fatal,  as  in  cases  where  the  abscess  is  opened 
without  the  precautions.  These  recommendations  are  all  the 
more  necessary,   as  the    treatment   may  be   extremely  pro- 


184  ANTISEPTIC    SURGERY. 

tracted.  This  is  one  of  the  cases  in  which  it  is  especially 
desirable  to  complete  the  dressing  at  its  periphery  with  sali- 
cylic wadding  or  boracic-acid  lint,  so  as  to  effectually  prevent 
the  entrance  of  air. 

Finally,  I  have  had  occasion  in  some  large  abscesses  to 
make. injections  of  a  ten-per-cent.  solution  of  chloride  of  zinc. 
I  have  made  this  addition  to  the  method  when  I  was  not  sure 
of  the  quality  of  the  dressing  and  of  the  antiseptic  precau- 
tions. In  the  case  of  a  young  man  who  had  an  immense 
abscess  in  the  dorso-lumbar  region,  I  made  two  of  these 
injections.  After  the  second,  he  had  a  pleurisy,  with  which 
the  injection  was  certainly  not  unconnected.  He  got  over 
his  pleurisy  very  well,  and  in  the  mean  time  the  purulent 
cavity  perfectly  closed,  and  did  not  re-open  in  the  ten  months 
during  which  I  kept  him  under  observation. 


CHAPTER   XXIII. 

Empyema.  —  Hypogastric   Lithotomy. 

One  would  expect  the  operation  for  empyema  to  give  exactly 
the  same  results  as  the  opening  of  abscesses  in  general,  and 
yet  it  is  undeniable  that  often  the  dressing  is  insuiiicient  to 
prevent  the  infection  of  the  cavity.  More  than  ordinary  pre- 
cautions are  necessary,  as  is  well  shown  in  a  case  reported  by 
John  Duncan  in  1878,  where  the  insufficiency  of  the  antisep- 
tic atmosphere  was  perfectly  evident. 

I  think  that,  in  many  cases,  one  may  dispense  with  injec- 
tions of  the  cavity,  at  least  for  a  long  time,  and  j'^et  he  is 
generally  led  to  make  them.  My  advice  in  such  cases  is  to 
distrust  carbolic  solutions,  which  are  very  rapidly  absorbed 
by  the  pleura,  and  to  use  instead  injections  of  boracic-acid 
water  or  even  a  weak  solution  of  chloride  of  zinc. 


Hypogastric  lithotomy. 

Many  authors  have  thought  supra-pubic  lithotomy  prefera- 
ble to  the  perineal  operation,  and  it  seems  as  if  the  antiseptic 
method  was  destined  to  dissipate  the  objections  made  to  the 
former.  The  facts  are  not  yet  sufficiently  numerous  for  us 
to  judge;  they  are  almost  all  derived  from  cases  in  infants, 
who,  on  account  of  their  tender  years,  present  a  condition 
peculiarly  favorable  for  hypogastric  lithotomy ;  and  yet  it  is 
clear  that  this  is  the  direction  in  which  progress  is  going  to 
be  made. 

13 


186  ANTISEPTIC    SUEGEEY. 

In  his  thesis  in  1873  Zayas  Bazan  described  an  operation 
which  he  saw  Professor  Lister  make  upon  a  boy  of  fourteen 
years.  The  peritoneum  was  opened,  and  then  closed  with  a 
suture.  The  bladder  was  sewed  up,  then  the  abdominal 
wall,  and  a  drain  was  inserted  under  this  suture.  The  recov- 
ery was  rapid. 

In  an  article  in  Hygiea,  in  1878,  Carl  Rossander  made  a 
long  plea  for  epicystotomy.  In  the  last  congress  at  Amster- 
dam, Dr.  Van  Goudaever,  of  Utrecht,  read  an  interesting 
article,  in  which  he  recommended  supra-pubic  lithotomy  in 
all  infantile  and  many  adult  cases. 

While,  in  perineal  lithotomy,  it  is  almost  impossible  to 
make  use  of  the  precautions  of  the  antiseptic  method,  it  is 
entirely  practicable  in  the  supra-pubic  operation. 

All  the  steps  of  the  operation  are  the  same.  Nearly  all 
authors  advise  complete  suture  of  the  vesical  walls  with  cat- 
gut. The  suture  of  the  abdominal  walls  should  be  incom- 
plete, an  opening  being  left  at  the  lowest  portion  for  the 
introduction  of  one  or  two  drains.  The  dressing  around  the 
penis  ought  to  be  made  with  great  care.  Lister  thinks  it 
desirable  to  complete  it  with  boracic  lint,  making  a,  sort  of 
sheath  for  the  organ.  According  to  most  authorities,  it  is 
better  to  practise  catheterism  than  to  let  an  instrument  re- 
main all  the  time  in  the  bladder. 


CHAPTER   XXIV. 

Castration    and    Operations    upon    the    Testicles.  —  Curb    of 
Hydrocele   by  Volkmann's   Method. 

Operations  upon  the  scrotum  require  peculiar  precaution 
on  account  of  the  mobility  of  the  parts,  which  necessitates 
the  application  of  a  generous  quantity  of  wadding  around  the 
ordinary  gauze  dressing.  The  conformation  of  the  region, 
also,  and  the  character  of  the  skin  call  for  much  more  care  in 
washing  than  any  other  parts.  However,  we  should  avoid 
letting  strong  solutions  of  carbolic  acid  remain  too  long  in 
contact  with  the  penis,  lest  severe  irritation  be  produced. 

Castration. 

The  use  of  the  catgut  ligature  makes  this  operation  very 
simple.  It  may  be  done  in  two  ways,  either  by  tying  the 
cord  in  a  mass,  or  by  dividing  it  into  two  or  three  portions 
and  ligating  each  separately.  It  has  been  proposed  to  isolate 
the  vessels  and  tie  each  by  itself ;  but  this  involves  unneces- 
sary trouble. 

The  catgut  does  not  separate,  and  the  extremity  of  the 
cord  is  not  thrown  off.  The  wound  is  closed  like  any  other, 
a  drain  being  introduced  at  the  most  dependent  part,  and 
withdrawn  after  a  few  days. 

I  removed  a  very  large  sarcomatous  testicle  from  a  patient 
a  while  ago,  and,  in  seventeen  days,  the  only  trace  of  the 
operation  was  a  linear  scar. 

The  decortication  or  simple  opening  of  hsematoceles  may  be 


188  ANTISEPTIC    SURGERY. 

effected  by  a  similar  procedure,  without  subjecting  the  pa- 
tient to  any  appreciable  risk. 

Hydrocele. 

It  is  well  known  that,  for  some  years,  Volkraann  has  prac- 
tised simple  incision  in  treating  hydrocele,  following  with  the 
suture  of  the  tunica  vaginalis.  Sometimes  a  drainage  tube  is 
employed,  and  sometimes  not ;  but  the  former  method  is  the 
more  prudent.  There  are  no  phenomena  of  inflammation  and 
no  suppuration.  The  time  required  for  the  cure  is  rather  less 
than  after  the  injection  of  iodine,  ten  or  twelve  days,  and  no 
ill  consequences  have  been  observed. 


CHAPTER    XXV. 

Operations  on  Tendons  and  their  Sheaths.  —  The  Opening  of 
Large  Cysts.  —  Club-foot.  —  The  Suture   of  Tendons. 

The  opening  of  the  sheaths  of  tendons  causes  suppuration 
no  more  than  the  opening  of  the  peritoneum  or  the  articula- 
tions. It  may  be  done  in  many  different  ways.  The  opening 
of  large  compound  ganglia  of  the  wrist,  formerly  so  greatly 
dreaded,  has  become  almost  common.  The  cyst  is  thoroughly 
emptied,  and  closed  up  with  sutures,  and  the  patient  quickly 
recovers. 

Cluh-foot. 

The  subcutaneous  method  of  operating  on  tendons  entirely 
loses  its  importance  in  the  presence  of  Listerism,  and  nothing 
is  easier  than  operating  with  everything  exposed  to  view,  as 
it  can  be  whenever  any  difficulty  arises.  There  are  plenty 
of  cases  already  on  record  in  which  the  division  of  tendons 
has  been  followed  by  immediate  union. 

The  suture  of  tendons. 

This  operation,  formerly  performed  frequently,  is  now  done 
with  catgut  in  much  more  favorable  conditions.  It  has 
already  been  made  so  many  times  in  different  circumstances 
that  it  is  quite  superfluous  to  cite  cases.  The  rules  for  the 
application  of  catgut  are  the  same  as  those  to  be  followed  in 
using  silver  wire,  only  that  no  provision  is  required  for  the 
cutting  of  the  stitches. 


■  CHAPTER   XXVI. 

Trephining    the    Skull, 

In  a  monograph  on  trephining  by  the  antiseptic  method,  I 
have  given  my  reasons  for  considering  this  operation  no  lon- 
ger grave,  but  one  which  may  be  made  without  apprehension. 
It  has  now  been  performed  a  good  many  times  by  the  Lister 
method.  The  only  things  about  it  which  require  especial 
mention  are  the  desirability  of  careful  drainage,  as  always  in 
large  wounds  of  the  head,  and  the  necessity  of  a  scrupulous 
preparation  of  the  surrounding  parts,  on  account  of  the  diffi- 
culty of  freeing  the  scalp  of  greasy  matters  which  pollute  it. 
In  a  case  of  hemorrhage  of  the  superior  longitudinal  sinus, 
Professor  Lister  carefully  plugged  the  entire  cavity  in  the 
skull  with  catgut.  The  bleeding  was  arrested,  and  there  was 
no  impediment  to  recovery. 


CHAPTER  XXVII. 

The  Treatment  of  Ulcers. — Epidermic  Grafting. 

Epidermic  grafting,  as  practised  by  my  colleague,  Dr. 
Jacques  Reverclin,  is  greatly  facilitated  by  the  Lister  method, 
indeed,  just  in  proportion  to  the  extent  to  which  we  render 
the  ulcers  aseptic  and,  consequently,  favorable  soil  for  the 
growth  of  the  grafts.  If  the  ulcer  is  not  of  very  long  standing, 
after  it  and  its  immediate  neighborhood  have  been  carefully 
bathed  in  carbolized  water,  it  will  be  sufficient  to  wash  its 
surface  with  an  eight-per-cent.  solution  of  chloride  of  zinc. 
It  is  then  covered  with  a  large  protective,  and  a  dressing  of 
boracic  acid  is  applied.  After  two  or  three  days,  we  cleanse 
the  ulcer  with  a  boracic  solution,  and  proceed  to  the  grafting. 

If  the  granulations  on  the  ulcer  are  well  formed,  there  is 
an  advantage,  before  applying  the  zinc,  in  cleaning  the  sur- 
face with  Volkmann's  curette,  for  the  purpose  of  removing  all 
exuberant  growths,  and  then  washing,  and  letting  the  wound 
rest  for  a  few  days  under  the  protective  and  a  boracic  dress- 
ing, the  latter  being  renewed  daily.  We  wait  some  days  that 
we  may  not  be  impeded  by  the  bleeding,  and  then  proceed 
to  graft  in  the  following  manner,  described  in  a  note  which 
Dr.  Reverdin  has  been  so  kind  as  to  write  me. 

The  almost  absolute  certainty  of  obtaining  immediate  union 
and  the  simplicity  of  the  progress  of  wounds  under  the  Lister 
dressing  ought  to  induce  all  surgeons  to  employ  it  in  epider- 
mic grafting  and  in  transplantations,  both  dermo-epidermic 
and  dermic.     Lister  himself,  in  a  lesson  upon  the  boracic  acid 


192  ANTISEPTIC    SURGERY. 

dressing,  devotes  to  the  subject  several  pages,  of  which  I  pre- 
sent a  resume.  The  skin  on  the  inner  aspect  of  the  fore-arm 
is  cleansed  with  the  strong  solution  of  carbolic  acid.  Then  a 
little  piece  of  it,  including  hardly  more  than  the  epidermis, 
is  removed,  and  being  placed  upon  the  thumb-nail,  moistened 
with  a  drop  of  boracic  solution,  is  cut  up  into  minute  frag- 
ments of  the  size  of  the  head  of  a  pin.  These  bits  are,  one  at 
a  time,  placed  upon  the  granular  surface  of  the  ulcer,  which 
has  been,  up  to  this  point  in  the  procedure,  carefully  covered 
with  a  piece  of  muslin  soaked  in  boracic  solution.  Now  only 
as  much  is  uncovered  at  a  time  as  is  necessary  for  tlie  de- 
positing of  each  graft ;  and,  as  fast  as  this  is  done,  the  part  is 
immediately  covered  again  with  a  little  piece  of  protective 
which  has  been  dipped  in  a  boracic  solution.  The  operation 
being  completed,  a  large  protective  is  spread  over  the  entire 
surface,  over  this  the  boracic  lint,  and  the  whole  is  secured 
by  a  bandage.  This  dressing  is  allowed  to  remain  for  two  or 
three  days,  and  is  then  removed.  One  must  content  himself 
with  cleansing  the  surroundings  of  the  ulcer,  and  avoid  touch- 
ing the  granulations  themselves,  lest  he  destroy  the  adhesions 
which  the  grafts  have  contracted.  Very  soon  an  epidermic 
zone  will  be  seen  developing  around  each  of  the  grafts  ;  and 
the  same  dressing  is  continued  until  the  breach  of  surface  is 
entirely  closed.  The  insignificant  wound  of  the  fore-arm  is 
at  the  same  time  dressed  with  protective  and  boracic  lint. 

In  some  cases,  Lister  substitutes  for  the  lint  a  piece  of 
cloth  spread  with  boracic  acid  salve  ;  but  every  graft  must 
be  shielded  from  contact  with  this  preparation  by  a  bit  of 
protective. 

It  is  probable  that  many  surgeons  have  used  the  boracic 
or  carbolic  dressing  in  grafting.  Reverdin  has  employed  the 
antiseptic  method  in  such  cases  a  number  of  times  with  con- 
spicuous success. 


GRAFTING.  193 

Volkmann,  of  Halle,  also  has  used  the  antiseptic  method 
in  these  cases.  He  generally  takes  large  grafts  and  places 
them  side  by  side,  so  as  to  cover  the  whole  surface  as  with  a 
mosaic.  This,  however,  would  hardly  be  accomplished  in 
surfaces  of  any  great  extent,  except  in  a  hospital,  where  the 
integuments  of  recently  amputated  limbs  can  be  utilized. 

Schede,  of  Berlin,  proceeds  thus  :  the  ulcer  is  scraped  with 
a  Volkmann  spoon,  so  as  to  obtain  a  bloody  surface  entirely 
freed  from  dirt ;  strong  disinfectants  are  applied  ;  then  dermo- 
epidermic  or  dermic  flaps  of  some  size  are  put  in  position, 
side  by  side,  like  a  mosaic  ;  and  the  antiseptic  dressing  is  put 
on.  The  success  is  generally  complete,  the  ulcer  being  closed 
in  a  few  days.  Schede  applies  the  dressing  in  the  following 
manner :  the  grafts  being  in  place,  he  takes  a  large  bandage 
of  antiseptic  gauze,  spreads  it  over  the  wound,  and  presses  it 
down,  thus  squeezing  out  the  blood,  which,  passing  through 
the  meshes  of  the  gauze,  is  stanched ;  then  he  rolls  the  ban- 
dage around  the  limb,  and  covers  it  in  with  the  Lister  dress- 
ing, omitting  the  protective. 

It  will  be  seen  from  what  precedes  that  there  are  several 
methods  of  grafting.  By  strict  attention  to  these  directions, 
we  are  sure  to  obtain  results  far  superior  to  those  formerly 
observed. 


CHAPTER    XXVIII. 

Ophthalmic  Surgery. 

The  Lister  method  has  been  employed  in  ophthalmic  sur- 
gery, and  with  a  certain  measure  of  success  ;  but  the  question 
of  the  best  antiseptic  has  somewhat  impeded  its  progress.  In 
most  cases,  indeed,  the  eye  will  not  endure  an  irritant  anti- 
septic, and  so  recourse  to  boracic  acid  has  been  advised,  or, 
after  having  taken  all  the  antiseptic  precautions,  the  employ- 
ment only  of  topics  which  are  aseptic  and  imputrescible,  like 
vaseline,  but  not  really  antiseptic,  in  the  proper  acceptation 
of  the  term. 

But  carbolic  acid  has  been  employed;  and  Dr.  Rossander, 
of  Stockholm,  pubhshed  in  1878  and  1879  the  results  of  his 
operations.  He  washes  the  patient's  face,  and  his  own  hands 
and  instruments  in  carbolic  water,  and  uses  the  spray  in 
cataract  operations,  dressing  with  antiseptic  gauze.  In  this 
way  he  made  twenty-seven  cataract  operations  without  a  case 
of  suppuration  either  of  the  cornea  or  of  the  entire  eye.  Up 
to  that  time  nothing  like  this  result  had  been  seen  in  that 
hospital. 

At  the  last  congress  at  Amsterdam,  Snellen  read  an  im- 
portant paper  which  proved  the  utility  of  the  following  pro- 
ceeding :  the  preliminary  washing  of  the  field  of  operation 
and  of  everything  which  is  to  touch  it  in  one-per-cent.  car- 
bolic water,  and  the  cleansing  of  the  instruments  in  alcohol, 
should  be  observed  in  any  operation  upon  the  cornea.  In 
such  cases,  the  use  of  the  spray  presents  decided  dijBficulties, 


OPERATIONS   ON   THE  EYE.  195 

and  is  successfully  replaced  by  a  current  of  air  purified  with 
carbolic  acid.  For  an  antiseptic  and  occluding  dressing,  it 
suffices  to  employ  pieces  of  cloth  saturated  with  vaseline  and 
bits  of  purified  cotton.  Irritant  antiseptic  preparations,  which 
augment  the  secretion  of  the  conjunctiva  and  palpebral 
glands,  ought  not  to  be  used. 

In  an  interesting  article  in  his  ophthalmological  review 
(November,  1879),  Galezowski  shows  how  he  has  put  in 
practice  the  principles  of  the  method.  In  a  general  way,  he 
employs  as  an  antiseptic  a  one-tenth-of-one-per-cent.  solution 
of  carbolic  acid.  The  eye-washes  are  more  frequently  made 
with  boracic  acid.  In  addition  to  these,  he  uses  only  pieces 
of  dressing  previously  disinfected.  These  precautions  have 
already  given  excellent  results.  All  these  precepts  are  good  ; 
and  yet  the  method  can  be  much  more  closely  followed.  In 
the  first  place,  all  the  general  precautionary  measures,  relat- 
ing to  the  surroundings  of  the  patient,  the  washing  of  instru- 
ments, hands,  etc.,  should  be  taken  just  as  for  other  operations, 
with  the  strong  solution. 

Operations  involving  the  transparent  media  will  not  permit 
free  washing  with  carbolic  acid,  but  a  boracic  solution,  even 
the  concentrated,  is  perfectly  well  borne.  The  spray  may  be 
used,  provided  the  spray -producer  is  sufficiently  removed,  and 
a  weaker  solution  than  usual  employed. 

Only  that  dressing  will  be  antiseptic  which  effects  occlu- 
sion, and,  for  this  purpose,  the  only  substance  which  is  en- 
tirely unobjectionable  is  the  boracic  lint.  I  have  used  it  in 
this  way,  and,  for  these  cases,  I  prefer  it  to  the  carbolized 
gauze.  According  to  circumstances  I  use  it  dry,  or  saturated 
with  an  aqueous  solution  of  boracic  acid. 

Operations  upon  the  conjunctiva  require  about  the  same 
precautions  against  the  irritant  action  of  a  powerful  anti- 
septic.    But  if  the  eye  is  destroyed,  as  in  enucleation,  or  if  the 


196  ANTISEPTIC    SUKGEEY. 

operation  is  outside  of  the  eye,  for  example,  autoplasty,  the 
carbolic  acid  resumes  its  place  in  our  esteem.  Nevertheless, 
I  advise  its  employment  in  connection  with  that  of  boracic 
acid.  For  example,  in  enucleation  I  freely  wash  the  cavity  of 
the  orbit  with  the  strong  solution,  and  then  dress  with  boracic 
lint.  I  used  to  put  under  the  lid  the  classic  wad,  making  it 
of  boracic  lint ;  but  now,  I  think  it  much  better  to  do  nothing 
of  the  kind,  and  simply  place  a  boracic  dressing  outside, 
keeping  it  there  until  cicatrization  is  perfect,  which  is  usually 
but  a  short  time. 

For  little  wounds  about  the  lids,  I  recommend  the  employ- 
ment of  boracic  ointment  spread  on  fine  cloth,  putting  over 
it  either  a  mackintosh  or  a  layer  of  boracic  lint,  according  as 
a  wet  or  dry  dressing  is  desired. 

It  will  be  seen  that,  by  following  these  directions,  the  ap- 
plication of  the  antiseptic  method  in  ophthalmic  surgery  is 
possible  and  even  easy.  It  will  be  noticed,  indeed,  that  here 
we  are  not  menaced  with  great  quantities  of  fluids  putrefying 
upon  the  dressing,  and  so  our  antisepsis  is  continually  fresh. 
But  it  must  not  be  forgotten  that  it  is  almost  impossible  to 
absolutely  purify  the  sulci  of  the  conjunctiva.  Boracic  acid 
and  vaseline  are  the  best  agents  to  employ  either  singly  or 
together. 

We  all  know  how  desirable  the  entire  absence  of  sup- 
puration is  in  ophthalmic  surgery,  and  understand  that  the 
attainment  of  this  end  ought  to  be  sought  with  unremitting 
zeal. 


CHAPTER  XXIX. 

Influence  of  Listerism  upon  the  Healthfulness  of  Hospitals. 

One  of  the  chief  advantages  of  the  method  is  its  favorable 
influence  upon  the  salubrity  of  hospitals.  All  the  operations 
which  I  have  mentioned  were  performed  in  hospitals  with 
absolute  safety.  It  was  in  a  hospital  that  Lister  made  his 
great  demonstrations  of  his  method  ;  and  in  the  wards  of  a 
hospital  I  myself  have  opened  joints  and  serous  cavities,  and 
dissected  veins,  without  any  fear  of  accident  or  contamination 
from  the  media. 

Every  wound  is  instantly  shut  up  in  an  antiseptic  atmos- 
phere, which  is  probably  even  purer  and  more  healthful  than 
mountain  air.  Of  course,  this  is  no  reason  for  neglecting 
hygienic  rules  and  seeking  for  bad  hospitals,  for  it  is  always 
wiser  to  have  as  few  and  as  insignificant  foes  to  contend  with 
as  possible  ;  but  it  is  a  reason  for  defying  infected  media,  if 
need  be,  and  for  using  existing  hospitals  with  proper  pre- 
cautions. 

If  the  method  is  constantly  employed,  it  exercises  a 
beneficent  influence  upon  the  general  salubriousness  of  the 
service.  The  action  of  perpetual  emanations  of  carbolic 
acid  is  obviously  favorable.  Soon  everything  becomes  im- 
pregnated with  it ;  even  the  drain-pipes  at  last  cease  to  emit 
any  putrid  odor.  This  was  the  experience  in  my  own  ser- 
vice, where  all  possible  pains  had  never  succeeded  in  disin- 
fecting a  certain  sink  in  the  obstetric  ward ;  but  now  that 
we  are  constantly  throwing  carbolized  water  into  it,  the  odor 


198  ANTISEPTIC    SUEGEEY. 

has  entirely  disappeared  without  any  one's  troubling  himself 
about  it. 

I  have  such  confidence  in  the  efficacy  of  these  means  that 
I  am  perfectly  convinced  that,  by  combining  thorough  car- 
bolic pulverization  and  washes,  we  might  clearly  rid  of  their 
baneful  influences  the  lurking-places  of  epidemics.  To  estab- 
lish the  correctness  of  this  view  would  require  a  far  greater 
number  of  facts  than  I  can  contribute  ;  and  yet  I  have  had 
experience  in  rooms  where  patients  have  sickened  and  died  of 
puerperal  fever,  erysipelas,  and  other  such  diseases,  and,  after 
I  had  employed  the  spray  and  washings,  no  evidences  of  con- 
tagion appeared.  This  limited  observation  of  mine  is  incon- 
clusive, but  it  is  in  a  direction  in  which  it  is  worth  while  for 
others  to  follow. 

The  spray  is  a  valuable  method  of  impregnating  anything 
you  please ;  and,  by  using  it  in  connection  with  the  purifica- 
tion of  cloths  and  garments,  by  means  of  superheated  air,  we 
are  destined  to  attain  results  the  entire  importance  of  which 
nobody  can  foresee. 

If  the  antiseptic  method  makes  hospitals  healthy  for  the 
present,  it  makes  them  so  for  the  future.  Whoever  desires 
to  profit  by  all  the  results  of  the  method  should  make  its 
application  as  extensive  and  as  general  as  possible  ;  and  day 
by  day  he  will  find  his  work  made  easier  by  the  progressive 
purification  of  the  media  in  which  he  performs  his  opera- 
tions. 

Finally,  let  us  not  lose  sight  of  the  fact  that  the  method  is 
of  advantage  to  the  surgeon  and  his  assistants  in  greatly 
diminishing  their  chances  of  meeting  with  accidents.  This 
comes  from  their  living  in  a  purified  atmosphere  and  having 
their  fingers  constantly  impregnated  with  the  substance  which 
is  most  powerful  in  neutralizing  every  kind  of  septic  matter. 
I  am  aware  that  this  suggestion  may  not  be  considered  chiv- 


PROTECTION   TO   THE   SURGEON.  199 

alrous,  and  sometimes  one  would  decline  to  entertain  it ;  and 
yet  it  seems  to  me  to  be  important,  for  our  assistants  pay  a 
cruel  tribute  to  wound  complications  by  the  lesions  which 
they  contract  in  the  wards ;  and  I  am  thoroughly  convinced 
that,  with  the  antiseptic  system,  this  heavy  burden  will  be 
lightened. 


CHAPTER   XXX. 

Carbolic  Acid  Poisoning.  —  Carbolic  Eczema. 

A  GREAT  cry  has  been  raised  about  the  toxic  properties  of 
carbolic  acid,  and  its  speedy  condemnation  has  been  pre- 
dicted, although  positive  facts  on  the  subject  are  so  ex- 
tremely rare  that  it  is  even  now  impossible  to  study  it  with 
any  great  satisfaction.  Kuster  has  investigated  it  more  care- 
fully than  anybody  else,  and  Nussbaum,  in  the  second  edition 
of  his  book  upon  the  antiseptic  dressing,  has  an  excellent 
chapter  on  the  subject. 

Undoubtedly  carbolic  acid  is  toxic ;  physiologists  have 
shown  upon  animals  that  it  acts  like  a  poison.  And  yet  it  is 
employed  in  enormous  doses  upon  human  beings  without  ac- 
cidents or  annoyance.  The  discoloration  of  the  urine,  which 
turns  green  and  black,  headache,  and  sometimes  gastralgia, 
are  the  most  common  phenomena  of  the  toxic  state  produced 
by  it.  In  some  cases,  which  are  infinitely  infrequent,  sud- 
den collapse  has  been  observed,  a  kind  of  sideration,  with 
loss  of  consciousness,  small  pulse,  and  cold  surface.  A  few 
of  these  cases  have  terminated  fatally,  but  the  most  have 
recovered. 

Some  individuals  evidently  have  a  peculiar  susceptibility 
to  the  acid,  of  which  I  have  seen  some  remarkable  illustra- 
tions. Poisoning  may  undoubtedly  occur  from  the  injection 
of  absorbent  cavities  from  which  the  return  of  the  liquid  has 
not  been  provided  for.  It  is  very  curious  that,  in  the  hands 
of  those  who  have  practised  antiseptic  surgery  most  —  Lis- 


SUSCEPTIBILITY   OF   CHILDREN.  201 

ter,  Volkmann,  Saxtorph,  and  myself  —  nothing  like  this 
has  ever  occurred.  Nussbaum,  who  has  reported  a  remark- 
able case,  points  out  how  accidents  may  be  avoided  in  these 
cases. 

Cases  in  which  strong  solutions  have  been  injected  into 
the  areolar  tissue  around  the  rectum  have  proved  fatal.  I 
have  seen  patients  with  abscess  of  the  iliac  fossa  and  with 
empyema  display  transitory  phenomena  of  poisoning,  which, 
however,  were  easily  dissipated. 

Prudence  should  be  exercised  in  certain  regions,  and  we 
ought  probably  to  take  into  account  some  cachectic  states ; 
but  especially  is  age  a  matter  of  moment.  Very  young 
children  are  singularly  susceptible  to  the  action  of  carbolic 
acid. 

For  a  long  time  I  have  thought  that  erythema  of  the  but- 
tocks, so  common  among  new-born  infants  who  are  attacked 
with  diarrhoea,  was  probably  parasitic  and  amenable  to  car- 
bolic acid.  One  day  last  year,  finding  some  babies  in  this 
condition  in  my  service  at  the  Cochin  Hospital,  I  ordered  a 
dressing  consisting  of  a  bit  of  fine  cloth  saturated  with  ten- 
per-cent.  carbolized  oil.  The  effect  was  excellent  and  speedy  ; 
the  nurses  in  charge  of  the  children  were  amazed,  and,  in- 
stead of  following  my  directions,  that  evening  they  conceived 
the  unhappy  thought  of  completely  enveloping  the  lower 
limbs  and  bodies  of  four  little  unfortunate  wretches  in  a 
large  compress  soaked  in  carbolized  oil.  At  my  visit  next 
day  I  found  these  babes  with  pinched  features  and  cold 
skins,  vomiting,  and  with  diapers  stained  black  by  the  urine. 
The  discovery  of  the  unfortunate  dressing  readily  explained 
their  condition.  Two  of  them  died ;  the  other  two  slowly 
recovered,  and,  strangely  enough,  were  completely  relieved 
of  their  erythema. 

I  have  continued  to  treat  cases  of  this  kind  with  carbolized 

14 


202  ANTISEPTIC    SUEGEEY. 

oil,  taking  care  to  repress  so  excessive  a  display  of  zeal  in  the 
nurses,  and  no  other  accident  has  ever  occurred.  I  mention 
the  occurrence  to  show  how  very  rapid  the  absorption  of  the 
acid  may  be  in  very  young  children,  and  that,  notwithstand- 
ing this,  it  may  be  used  with  proper  precautions. 

We  must  always  remember  that,  like  all  other  active 
agents,  carbolic  acid  has  certain  undesirable  properties,  for 
which  we  must  be  constantly  on  our  guard. 

In  cases  where  we  are  obliged  to  leave  injected  fluids  in  an 
absorbent  cavity,  we  must  avoid  the  employment  of  strong 
solutions,  or  even  substitute  chloride  of  zinc  for  carbolic  acid. 
When,  in  patients  with  wounds,  the  urine  continues  black, 
nausea  arises,  and  gastralgia  and  headache  persist,  we  must 
either  lessen  the  doses  or  discontinue  the  use  of  the  acid. 

But  we  should  neither  dispense  with  this  powerful  agent, 
nor  make  such  assertions  aboul^  its  dangerous  properties  as  is 
done  in  a  report  in  the  Centralhlat  f.  med.  Wissenschaften 
(7th  September,  1878),  in  which  it  is  related  that  poisoning 
occurred  on  account  of  a  utero-vaginal  injection,  the  liquid 
having  passed  into  the  peritoneum. 

The  most  perilous  region  as  regards  the  action  of  carbolic 
acid  is  the  perirectal,  the  most  of  the  serious  cases  having 
been,  as  was  previously  remarked,  those  in  which  injections 
were  made  into  the  areolar  tissue  of  this  locality. 

It  would  be  well,  also,  to  avoid  the  excess  in  employing 
carbolic  acid  in  which  certain  imitators  of  Lister  indulge, 
offsetting  their  lack  of  precision  in  the  observance  of  his 
directions  by  an  extraordinary  misuse  of  the  antiseptic. 
After  having  observed  these  modes  of  operating,  one  cannot 
escape  the  conviction  that  the  danger  in  using  carbolic  acid 
is  extremely  small,  for  no  harm  comes  from  this  unwarrant- 
ably lavish  employment  of  it.  But  that  is  no  good  reason  for 
following  such  an  example. 


TREATMENT   OF   POISONING.  203 

There  is  one  other  point  which  it  is  necessary  to  take  into 
account -the  quality  of  the  acid.  In  France,  our  acid, 
even  the  crystallized,  is  very  bad  smelling,  and  contains  some 
toxic  impunties;  but  I  have  every  reason  for  believing  that. 
If  a  perfectly  pure  article  is  used,  such  as  may  be  obtained 
from  certam  drug  establishments  which  purify  it  themselves, 
the  chances  of  accident  are  infinitely  reduced 

Theoretically,  the  sulphate  of  sodium  is  admitted  to  be 
the  antidote  to  carbolic  acid,  and,  in  case  of  poisoning,  Nuss- 
baum  recommends  the  following  prescription  :  - 

Sulphate  of  sodium ,      5  g.,,^^^ 

Distilled  water ^5q       ,, 

Syrup  of  raspberries 25       " 

Of  this  two  spoonfuls  are  to  be  taken  erery  two  hours.  In 
cases  of  profound  collapse,  he  especially  advises  artificial 
respiration. 

Carbolic  eczema. 

Most  cases  of  this  affection  result  from  holding  the  spray- 
produeer  too  near  the  part  operated  npon.  Cases  in  which  ' 
the  skm  cannot  endure  carbolic  acid  at  all  are  veiy  rare 
I  have  i-eported  the  case  of  a  young  man  one  of  whose  toes" 
I  amputated.  He  had  so  severe  an  eczema  on  the  dorsnm  of 
his  foot  that  I  was  forced  to  use  the  boraoic  acid  instead. 
In  fact  boraco  acid  is  our  best  resource  when  we  require  an 
antiseptic  which  is  entirely  free  from  irritating  properties. 


CHAPTER    XXXI. 

Objections  to  the  Antiseptic  Method. 

The  great  success  of  Listerisin,  its  achievements,  so  almost 
incredible  from  the  point  of  view  of  received  ideas,  its  prac- 
tice, so  profoundly  modifying  the  common  course  of  surgery, 
naturally  aroused  lively  antagonism.  Antiseptic  surgery 
was  scarcely  invented  before  violent  war  was  made  on  it, 
from  which  the  amenities  of  science  were  to  a  large  extent 
excluded.  From  the  very  beginning.  Lister's  invention  was 
disputed.  In  a  curious  article  (Lancet,  1867)  the  illustri- 
ous Simpson  attributes  this  discover}'-  to  all  surgeons  suc- 
cessively, at  the  same  time  declaring  the  method  to  be 
absurd  and  bad.  Since  then  there  has  been  written  no  dia- 
tribe which  is  either  better  or  worse. 

When  Lister  had  succeeded  in  proving  that  he  claimed 
neither  the  discovery  of  carbolic  acid  nor  the  surgical  em- 
ployment of  antiseptics,  but  an  ensemble  of  measures  for  anti- 
septic protection,  for  the  defence  of  the  organism  by  definite 
means,  then  discussion  was  directed  to  the  principles,  the 
nature,  and  the  mode  of  action  of  the  dressing. 

It  was  alleged  that  there  was  nothing  new  in  it ;  it  was 
only  a  variety  of  dressings  by  occlusion.  It  is  sufl&cient, 
however,  to  have  seen  the  dressing  but  once,  or  to  have 
attentively  read  a  description  of  it,  to  become  convinced  that 
it  is  not  an  occlusion  dressing. 

Others,  better  informed,  recognized  in  it  a  variety  of  in- 
frequent dressing,  and  generally  went  back  to  the  celebrated 
descriptions  of  Magatus  in  1616.     But  the  dressing  is  infre- 


OBJECTIONS.  205 

quejit  only  to  those  who  do  not  know  how  to  apply  it.  In- 
deed, it  is  necessary  to  renew  it  very  soon  after  the  opera- 
tion, and  one  can  rarely  avoid  a  renewal  within  the  first 
twenty-four  hours.  After  this,  the  dressings  become  infre- 
quent onl}'-  in  proportion  to  the  length  of  time  which  has 
elapsed  since  the  operation.  Are  not  these  indications  ex- 
actly opposite  to  those  of  the  infrequent  dressing  ? 

Others  still  have  argued,  a  'priori,  that  the  dressing  could 
be  of  no  use,  because  the  micro-organisms  counted  for  noth- 
ing in  the  causation  of  accidents ;  that  putrefaction  is  accom- 
plished independently  of  them ;  and  that,  at  most,  they  are 
but  a  product.  It  is  even  added,  as  a  general  thing,  that  the 
wounds  which  have  putrefied  the  most  are  most  exempt  from 
accidents. 

I  shall  not  discuss  this  argument  here.  It  is  perfectly  cer- 
tain that  the  more  perfect  the  defence  against  germs  is,  the 
better  are  the  results  of  surgical  operations.  Under  the 
Lister  dressings,  the  micro-organisms  are  very  rare  and  of  a 
low  grade  of  vitality. 

Not  only  do  we  not  deny  that  wounds  heal  even  though 
they  be  infested  with  micro-organisms,  but  we  believe  that 
the  explanation  of  the  fact  is  to  be  found  in  the  power  of 
resistance  possessed  by  the  healthy  tissues  and  in  the  variety 
of  the  organisms,  some  destroying  others. 

But  if  all  this  carried  no  conviction,  if  the  theory  were 
utterly  false,  the  practice  remains,  and  some  other  explana- 
tion of  its  results  must  be  sought.  A  chemical  theory  might 
be  advanced,  but  there  are  no  facts  to  support  it.  Under  the 
influence  of  well-applied  antiseptic  protections,  the  repair  of 
wounds  is  metamorphosed. 

As  far  as  the  putridity  of  wounds  is  concerned,  there  are, 
indeed,  surgeons  who  do  not  take  pains  enough  to  avoid  it, 
but  there  is  none  who  goes  so  far  as   to  seek  for  it  for  the 


206  ^  ANTISEPTIC    SURGERY. 

sake  of  putting  himself  in  accord  with  pretended  scientific 
theories. 

Still  others  think  that  the  general  condition  determines  the 
fate  of  the  patient  who  undergoes  an  operation :  that  he  will 
recover  if  this  is  good,  will  die  if  it  is  bad.  But  the  sur- 
geons who  are  most  resolutely  antiseptic  in  their  ideas  do  not 
question  the  large  part  played  by  the  precedent  condition  of 
the  organism  ;  in  their  opinion,  even,  that  which  proves  the 
excellence  of  the  method  is  that  the  influence  of  the  state  of 
the  system  loses  a  great  deal  of  its  importance,  as  repair  be- 
comes so  easy,  and  we  dare  to  operate  upon  patients  whose 
general  condition  would,  but  for  Listerism,  make  us  hesitate. 
An  eminent  master,  who  for  a  long  time  has  devoted  great 
attention  to  the  influence  of  constitutional  states,  Professor 
Verneuil,  emphatically  expresses  this  opinion. 

Some  other  authors  have  been  willing  to  admit  that  the 
method  possesses  some  virtue,  but  this  they  ascribe  to  its  an- 
tagonism to  contagion,  although  Lister  has  not  thought  of 
this  contagion.  One  must  be  very  little  acquainted  with  the 
surgeon  and  very  ignorant  of  his  method  to  advance  this 
argument.  It  will  suffice  to  have  read  my  description  to  see 
that  his  object  is  to  avoid  something  very  different  from  con- 
tagion. 

More  direct  objections  to  the  practice  have  been  made, 
which  constitute,  in  the  minds  of  some  authors,  insurmount- 
able obstacles  to  its  progress.  Those  who  have  made  these 
criticisms  have  a  poor  understanding  of  the  method  —  some- 
times none  at  all. 

It  has  been  especially  alleged  that  it  seriously  complicates 
the  operations.  A  good  spraj^-producer  does  not  interfere  in 
any  way,  and  it  would  be  childish  to  consider  the  other 
precautions  as  impediments. 

It  is  asserted  that  the  dressing  is  difficult,  tedious,  necessi- 


A   PAINLESS   DRESSING.  207 

tating  the  presence  and  assistance  of  the  chief  of  the  service, 
that  it  is  distressing  and  painful  to  the  patient.  As  far  as  all 
this  is  concerned,  I  can  say  that  I  have  never  yet  seen  a  good 
interne  who  did  not  apply  the  dressing  rapidly  and  well ;  and 
this  is  the  more  to  be  expected,  as  the  dressings  are  strik- 
ingly similar  in  all  cases.  As  there  are  fewer  of  them  to 
make,  it  is  perfectly  plain  that,  in  the  long  run,  a  patient 
requu'es  much  less  time  and  attention  than  if  he  were 
dressed  by  any  other  method. 

The  dressings  are  not  painful,  because  they  are  not  un- 
clean, because  they  do  not  torment  the  wounds  by  frictions 
and  bathings,  and  especially  because  they  do  not  excite  any 
inflammatorj'^  action.  And,  furthermore,  carbolic  acid  does 
not  cause  pain,  as  alcohol  does,  for  example.  Far  from  this, 
we  know  that  it  actually  has  anaesthetic  power.  Above  all, 
with  the  spray,  we  can  perform  operations  which  are  not 
very  painful  upon  infants  without  anaesthetizing  them.  I 
have,  indeed,  made  several  operations  without  using  chloro- 
form, and  the  patients  have  evidently  suffered  very  little. 
At  the  Saint  Louis  Hospital,  Lai  tier  is  at  the  present  time 
employing  the  carbolic  spray  to  produce  anaesthesia  of  the 
skin  in  cases  of  violent  pruritus.  He  was  led  to  pursue  this 
course  by  the  remarks  made  by  several  of  us  at  the  Surgical 
Society  upon  the  anaesthetic  property  of  carbolic  acid. 

Great  objection  has  been  made  to  the  dressing  on  account 
of  its  costliness  —  a  consideration  of  some  importance  in  hos- 
pital service.  I  am  prepared  to  assert  that  this  is  a  remark- 
able exaggeration,  and  I  have  good  reason  for  knowing,  as, 
during  the  first  six  months,  I  dressed  at  my  own  expense  all 
the  patients  on  whom  I  operated.  I  privately  imported  from 
Edinburgh  all  the  materials,  when,  too,  they  were  very  high- 
priced.  1  found  the  expense  of  the  pieces  necessary  for  the 
seven  dressings,  after  an  amputation  of  the  leg  at  the  upper 


208  ANTISEPTIC    SUEGEEY. 

third,  to  be  about  two  dollars  and  forty  cents.  This  patient 
was  healed  in  twenty-four  days,  and  was  able  to  leave  the 
hospital  on  the  thirtieth.  In  Nussbaum's  excellent  work 
I  find  an  estimate  of  the  pieces  of  dressing  which  he  con- 
siders necessary  in  a  thigh  amputation,  and,  reckoning  on 
the  same  basis,  fifteen  dressings  would  cost  about  five  dol- 
lars. Since  that  time  the  price  of  the  materials  has  been 
greatly  reduced,  so  that,  if  one  does  not  waste  the  pieces, 
as  I  have  often  seen  done,  the  dressing  is,  in  reality,  quite 
inexpensive,  far  more  economical,  indeed,  than  most  of  the 
dressings  employed  to-day  in  hospitals,  where  alcohol  almost 
always  plays  an  important  role. 

It  may  be  added  that  the  patients  do  not  suffer,  have  no 
fever,  enjoy  their  food,  require  no  costly  medicines,  and  have 
no  need  of  especial  attentions.  But,  above  all,  the  rapidity 
of  healing  is  extraordinary  ;  and,  were  its  only  advantage  the 
abridgment  of  the  patient's  stay  in  the  hospital,  the  method 
would  be  a  great  piece  of  economy.  In  his  very  remarkable 
book  upon  antiseptic  surgery,  Nussbaum  shows  that  the  sub- 
jects of  amputation,  by  the  shortening  of  their  sojourn,  cost, 
at  the  rate  of  fifty  cents  a  day,  from  seventy-five  to  one  hun- 
dred dollars  less  than  formerly.  It  is  easy  to  see  that  a  great 
saving  is  made  in  the  Paris  hospitals,  also,  where  the  cost  per 
diem  is  about  fifty-three  cents  a  patient.  Each  dressing  at 
the  highest  price  costs  only  from  twenty  to  thirty-five  cents, 
and  the  abbreviation  of  the  stay  in  the  hospital  varies  be- 
tween fifteen  days  and  three  months.  The  objectors  to  the 
method  say  that  carbolic  acid  is  irritant,  and  insupportable 
to  the  patient  and  the  surgeon  —  an  argument  reproduced 
within  a  month  at  the  Surgical  Society.  It  is  necessary,  to 
start  with,  to  have  a  clear  understanding  as  to  this  word 
"  irritant."  If  they  mean  that  carbolic  acid  is  caustic,  and 
that  it  attacks  the  epidermis  of  the  operator,  thus  making  it 


AN   ERROR   CORRECTED.  209 

a  little  disagreeable  for  him  at  times,  the  statement  is  true ; 
but,  if  they  mean  that  the  acid  irritates  the  wounds,  that  it 
excites  inflammatory  complications,  it  is  false,  at  least  in  the 
case  of  any  man  who  knows  how  to  use  it.  Indeed,  it  is 
strictly  forbidden  to  let  the  carbolic  acid  remain  in  contact 
with  the  wounds,  with  tissues  in  the  course  of  repair ;  but  its 
temporary  contact  with  a  wound  causes  no  irritation.  Like 
all  other  disciples  of  Lister,  I  have  washed  with  it  the  most 
sensitive  tissues  — the  peritoneum,  the  synovial  membrane 
of  the  knee-joint,  the  tissues  of  the  orbit,  the  dura  mater  — 
and  I  have  never  seen  any  of  the  phenomena  of  irritation. 
If  any  one  does  see  them,  it  is  because  he  has  failed  to  follow 
the  precepts  which  I  have  laid  down. 

The  dressing  has  been   accused  of  favoring   hemorrhage, 
and  Demarquay  has  been  particularly  strenuous  upon  this 
point.     The  value  of  his  observations  is  indisputable  ;  but  as 
he  has  evidently  fallen  into  an  error  here,  I  dwell  a   moment 
upon  this  point.    It  is  true  that  carbolic  acid  is  not  hemostat- 
ic, and  irrigation  during  an  operation  may  rather  favor  the 
discharge  of  blood  than  check  it;  but,  for  my  part,  I  see  no 
harm  in  that,  for  I  am  not  averse  to  leaving  in  the  wound  as 
many  ligatures  as  may  be  necessary  to  check  this  bleeding, 
tying  veins  as  well  as   arteries.     If  secondary  hemorrhage' 
comes  on,  the  operator  must  take  the  blame  of  it.    Once  I  had 
such  a  case,  in  which  profuse  bleeding  occurred  after  eight 
hours,  entirely  due  to  the  fact  that  I  had  neglected  the  liga- 
ture of  an  important  artery.     Furthermore,  we  should   re- 
member that  the  majority  of  operations  upon  the  extremities 
at  present  are  made  with  the  application  of  the  Esmarch 
bandage,  or,  at  least,  with  a  rubber  ring  around  the   upper 
part  of  the  limb.     This  method,  too  generally  adopted,  is  the 
great  cause  of  secondary  hemorrhages,  and  I  have  long  be- 
lieved that  the  Esmarch  bandage  is  far  from  being  indispens- 


210  ANTISEPTIC    SURGERY. 

able,  except  in  a  few  cases,  such  especially  as  the  search  for 
a  divided  vessel,  and  the  destruction  of  diseased  portions  of 
bone.  A  better  means  is  needed,  by  which  we  can  make  less 
compression  and  produce  less  paralysis.  The  modification 
designed  by  my  colleague,  Dr.  Nicaise,  gives,  in  this  respect, 
very  satisfactory  results. 

When  the  blood  is  well  stanched,  even  if  a  little  oozing 
still  continues,  the  dressing  may  nevertheless  be  applied, 
light  compression  being  employed.  The  discharge  soon 
ceases,  and  the  blood  which  escapes  under  the  flaps  does  not 
hinder  union. 

Other  objections  are  of  more  importance.  The  odor  of 
carbolic  acid  is  disagreeable  to  some  patients ;  but  I  have 
rarely  heard  any  serious  complaint.  . 

The  odor  is  more  distasteful  to  the  surgeon,  because  it 
impregnates  his  hands  and  his  garments.  If  the  acid  is  of 
good  quality,  this  odor  is  less  penetrating,  and  one  may  lessen 
its  effects  by  various  means.  I  am  convinced  that  some  other 
substance  will  be  discovered  equally  good  for  washing  the 
hands. 

Carbolic  acid  is  sometimes  irritant  to  the  skin,  and,  in  such 
a  case,  that  which  is  of  poor  quality  should  be  thrown  away. 
Very  rarely  it  awakens  under  the  dressing  a  sort  of  eczema 
in  people  who  are  especially  susceptible.  The  substitution 
of  boracic  acid  easily  remedies  this  difficulty.  This  irritation 
is  more  seriously  disagreeable  for  the  surgeon's  fingers,  which, 
being  often  wet  with  the  strong  solution,  become  harsh  and 
rough,  and  are  also  the  seat  of  annoying  prickling.  By  taking 
care,  this  inconvenience  may  be  partially  avoided.  To  me, 
these  are  the  only  serious  objections  to  the  method,  and  I 
certainly  do  not  find  them  sufficient  to  induce  me  to  throw 
it  aside. 

With  still  more  reason  do  I  find  myself  completely  insen- 


INCONSISTENT   OBJECTORS.  211 

sible  to  the  objection  of  those  who  consider  these  surgical 
complexities  inadmissible,  who  think  that  all  surgery  may 
be  done  with  a  bistouri  and  a  bit  of  charpie,  provided  there 
is  a  stream  of  water  in  the  neighborhood.  This  does  not 
prevent  them  from  planning  hospitals  which  cost  millions, 
and  inventing  cunningly  devised  instruments,  which  are  very 
expensive  for  a  single  patient  ;  and,  besides,  they  do  not 
neglect  to  comfort  their  patients  with  costly  medicines,  pro- 
vided that  all  this  does  not  deviate  too  much  from  approved 
usages.  Then,  after  all,  the  patients  who  have  been  operated 
on  with  the  bistouii  and  bit  of  charpie,  in  the  hospital  or 
even  in  the  city,  will  have  first  to  escape  the  actual  dangers 
to  which  they  are  exposed,  and  then,  in  the  most  favorable 
circumstances,  will  be  obliged  to  devote  two  or  three  months 
to  the  cicatrization  of  a  wound  which  ought  to  be  healed 
in  fifteen  davs  or  three  weeks. 


CHAPTER    XXXII. 

The  Employment  of  Various  Means  when  the  Elements  of  the 
Antiseptic   Method   fail. 

To  make  this  chapter  exhaustive,  it  would  be  necessary  to 
review  all  the  substances  proposed  in  the  last  ten  years,  and 
this  simple  examination  would  assume  frightful  proportions. 
It  is  unnecessary,  however,  to  undertake  this  task,  for  the 
ingenuity  of  the  surgeon  will  be  able  to  meet  the  emergen- 
cies which  arise  when  the  ordinary  means  fail.  It  will  be 
sufficient  for  him  to  bear  in  mind  the  following  precepts :  — 

First.  Emollient  epithems  of  various  kinds  are  nests  all 
ready  for  micro-organisms. 

Second.  So-called  pure  water  is  often  loaded  with  enemies, 
as  Pasteur  has  so  well  demonstrated.  Therefore,  the  use  of 
epithems  and  pure  water  should  be  abandoned. 

Third.  Carbolic  acid  is  now  so  common  that  aqueous  solu- 
tions can  be  made  almost  anywhere. 

Fourth.  All  antiseptics  of  the  same  family  may  be  em- 
ployed, as  borax,  alum,  tannin,  sulphate  of  zinc,  chloride  of 
zinc,  and  such  other  agents. 

Fifth.  Among  the  vegetable  substances  easily  found  in  the 
fields,  the  green  rind  of  the  walnut,  the  walnut-leaf,  oak- 
bark,  afford  decoctions  which  are  sufficiently  antiseptic  in 
media  which  are  not  very  dangerous.  Tar  is  a  substance  of 
the  very  greatest  worth. 

Solutions  of  carbolic  acid  in  glycerine  and  especially  in  oil 
are  of  peculiar  value,  since  the  acid,  when  dissolved  in  these 
substances,  is  scarcely  irritant,  and  a  wound  may  be  dressed 


SUBSTITUTES.  213 

with  a  twenty-per-cent.  oily  solution  without  excessive  irrita- 
tion. Nevertheless,  it  is  better  to  use  solutions  of  less 
strength,  as  the  more  powerful  lay  one  liable  to  toxic  acci- 
dents. Thus,  dressings  with  ten-  or  even  five-per-cent.  car- 
bolized  oil  are  of  very  great  service  where  frequent  renewal 
is  demanded. 

Wadding  impregnated  with  five-  or  ten-per-cent.  carbolized 
glycerine  makes  a  valuable  dressing.  Even  in  an  antiseptic 
hospital,  when  patients  enter  with  abundant  suppuration,  it 
performs  important  service. 

I  used  often  to  employ,  especially  in  dressing  patients 
operated  on  for  strangulated  hernia,  layers  of  agaric  saturated 
with  weak  carbolic  solution.  In  other  cases,  I  used  charpie 
soaked  in  this  solution,  always  observing  the  other  precau- 
tions of  the  method,  and  covering  the  dressings  with  an  im- 
permeable ;  in  suppurations  I  had  thus  a  veritable  cataplasm. 

In  using  vaseline  or  boracic  ointment,  one  can  easily  follow 
out  the  principles  of  the  method  in  simple  cases. 


CHAPTER   XXXIII. 

Formula  for  preparing  the  Materials  employed  in  the 
True  Lister  Dressing. 

Carbolic  acid. 

It  is  well  to  remember  that  there  is  a  much  wider  choice  of 
antiseptics  than  most  of  us  have  been  accustomed  to  suppose. 
Professor  Lister  has  not  simply  introduced  carbolic  acid  into 
surgical  practice ;  he  has  invented  a  method  which  demanded 
the  employment  of  the  best  antiseptics.  After  a  great  many 
trials,  he  has  selected  several  which  he  has  found  useful. 
But,  up  to  the  present  time,  he  has  found  no  agent  which  is 
as  valuable  as  carbolic  acid  for  the  habitual  destruction  of 
micro-organisms  and  for  its  action  upon  recent  wounds.  It 
cannot  be  said  to  be  the  best  in  every  case,  and  for  certain 
purposes  Lister  does  not  use  it.  He  recommends  other  sub- 
stances in  cases  where  the  method  cannot  be  rigorously 
applied.  I  am  quite  certain  that  the  surgeon  who,  after 
having  become  familiar  with  the  principles  of  the  method, 
attentively  studies  the  chapter  on  its  practice,  will  be  able, 
even  though  he  cannot  obtain  the  materials  for  the  per- 
fect Lister  dressing,  to  institute  an  antiseptic  treatment 
which  will  always  give  favorable  results,  because  the  first 
attempts  of  the  master  himself,  imperfect  as  we  must  consider 
them,  constituted  a  great  advance  in  surgery. 

The  employment  of  carbolic  acid  presents  indisputable  and 
undenied  disadvantages,  which,  however,  are  compensated 
for  by  advantages  which  are  not  less  indisputable.  Its  odor, 
causticity,  and  poisonous  properties   are   objections,  as  we 


PHENOL.  215 

have  alreadj''  seen  ;  and  I  would  remind  all  who  contemplate 
using  it  that,  in  spite  of  the  progress  of  industry,  it  is  still 
burdened  with  a  multitude  of  impurities.  We  should  never 
employ  the  uncrystallized  acid  ;  and  there  is  some  choice 
even  among  the  crystallized  specimens,  for  they  are  liable  to 
contain  various  alkaloids,  which,  more  than  any  other  sub- 
stances, impart  to  it  harmful  properties.  That  which  has 
most  transparency  and  least  odor  has  as  powerful  antiseptic 
qualities  as  any,  and  the  fewest  disadvantages. 

The  carbolic  acid  which  combines  these  conditions  is  the 
product  which  is  known  in  England  as  absolute  phenol,  and 
possesses  the  additional  merit  of  being  so  much  more  soluble 
that  a  five-per-cent.  aqueous  solution  can  be  made  without 
the  addition  of  alcohol. 

The  disadvantages  of  carbolic  acid  may  be  remedied  by 
associating  it  with  other  substances,  one  or  another  being 
chosen  according  to  circumstances.  For  example,  being  vol- 
atile and  very  soluble  in  alcohol,  it  is  given  up  by  the  liquid 
with  great  ease,  indeed,  we  may  say  immediately.  Thus 
the  alcoholic  solution  is  caustic  and  may  furnish  rapidly  large 
quantities  of  the  acid,  when  an  extensive  and  powerful  appli- 
cation is  necessary.  In  water,  the  acid  is  a  little  more  fixed, 
and  thus  the  aqueous  solutions  are  more  manageable  and  are 
very  widely  used ;  but  even  water  parts  with  the  acid  so 
speedily  that  these  solutions  are  bad  agents  for  permanent 
dressings. 

In  order  to  insure  the  solution  of  the  common  varieties  of 
the  acid,  it  is  always  the  rule  to  add  alcohol ;  but  as  little 
as  possible  should  be  used,  for,  if  there  is  a  considerable 
proportion  of  alcohol,  these  solutions  really  become  a  little 
irritant. 

Some  little  care  should  be  devoted  to  the  preparation  of 
the   aqueous  solutions.      They  should  be   made  some  time 


216  ANTISEPTIC    SUKGERY. 

before  they  are  to  be  used,  as,  after  standing  a  while,  any 
undissolved  globules  may  be  more  easily  detected,  and  the 
solution  will  then  be  filtered;  for,  if  these  globules  be 
allowed  to  come  in  contact  with  the  skin,  they  will  produce 
a  disagreeable  burn. 

I  have  many  times  compared  the  effects  of  very  pure  and 
of  impure  carbolic  acid.  One-to-forty  solutions  of  the  former, 
in  permanent  contact  with  the  tissues,  cause  no  incon- 
venience ;  solutions  of  the  latter  of  the  same  strength  some- 
times produce  vesication. 

In  order  to  avoid  the  disadvantages  arising  from  the  addi- 
tion of  alcohol,  I  dissolve  the  acid  in  glycerine,  and  then  add 
the  water  without  alcohol.  Glj^cerine  dissolves  the  acid 
more  perfectly  and  rapidly  than  alcohol  does.  The  propor- 
tion required  is  the  same  as  that  of  alcohol.  Solutions  thus 
prepared  are  much  less  caustic  and  less  disagreeable  to 
employ  than  the  others.  They  may  be  used  for  all  purposes. 
It  is  true  that,  when  they  are  used  for  the  production  of  the 
spray,  the  tubes  are  more  easily  clogged ;  but  this  incon- 
venience may  be  avoided,  and  we  have  the  advantage  of  a 
much  more  perfect  cloud. 

Aqueous  solutions. 

The  following  are  the  formulae  for  the  most  commonly 
used  solutions.  In  order  to  keep  the  nurses  from  making 
any  mistake  in  them,  I  am  accustomed  to  color  the  strong 
solution  red. 

Strong  aqueous  solution,  red. 

Carbolic  acid  crystals    ....  50  grams. 

•     Alcohol 50      " 

Water 1,000      " 


FORMULiE.  217 

Weak  aqueous  solution. 

Carbolic-acid  crystals    ....  25  grams, 

Alcohol 25      " 

Water 1,000      " 

Ver^/  strong  alcoholic  solution. 

Carbolic-acid  crystals 10  grams. 

Alcohol  . 50      " 

Instead  of  these,  I  recommend  the  following  solutions, 
which,  as  I  have  said  before,  are  preferable,  even  for  the 
spray. 

■  Strong  aqueous  solution,  red. 

Carbolic-acid  crystals     ....  50  grams, 

Glycerine 50      " 

Water 1,000      " 

Weak  aqueous  solution. 

Carbolic-acid  crystals     ....  25  grams. 

Glycerine 25      " 

Water 1,000      " 

Carbolized  oil  and  glycerine. 

The  acid  dissolves  well  in  both  these  substances,  and  the 
solutions  are  very  manageable.  The  oil  parts  with  the  acid 
which  it  contains  much  more  slowly  than  either  alcohol  or 
water ;  and,  therefore,  before  the  employment  of  the  gauze, 
it  was  the  carbolized  oil  which  Lister  selected  for  his  anti- 
septic agent. 

15 


218  ANTISEPTIC    SUHGEEy. 

Two  different  strengths  of  the  oil  are  generally  used. 
The  first  is  employed  to  lubricate  catheters,  trocars,  specula, 
etc.,  and  is  composed  of 

Carbolic-acid  crystals 5  grams, 

Olive  oil 100      " 

The  second  is  used  in  dressings,  and  contains  — 

Carbolic-acid  crystals 10  grams, 

Olive  oil 100      " 

Certain  dressings  which  require  to  be  frequently  renewed 
are  made  of  lint  or  charpie  saturated  with  this  oil.  In 
France,  in  place  of  lint,  we  use  wadding  or  compresses  im- 
pregnated with  it.  The  dressings  often  need  to  be  changed 
twice  a  day. 

I  have  often  applied  such  an  oiled  compress  to  inflamed 
parts  in  place  of  a  cataplasm,  putting  a  layer  of  wadding 
above  it,  and  outside  of  this  the  impermeable.  The  patients 
seem  to  be  as  much  relieved  as  by  a  poultice,  and  do  not  incur 
the  dangers  inherent  in  the  dirty  epithems. 

Giauze. 

This  is  made  of  fine,  unbleached  tarlatan,  washed,  to  make 
it  more  pervious,  and  dried.  Pieces  five  or  six  meters  long 
are  folded  into  squares,  heated  in  a  stove,  and  then  treated 
with  the  following  mixture  :  — 

Carbolic-acid  crystals  ...     1  part  by  weight. 

Common  resin 5  parts     "       " 

Paraflan 7      "        "       " 

The  resin  and  parafQn  are  to  be  mixed  in  a  water-bath,  and 
the  carbolic  acid  added  gradually. 

The  mixture  is  applied  by  means  of  a  syringe  with  a  large 
nozzle,   which  is  perforated  with  a  number  of  holes,   each 


HOW   TO   PREPARE   GAUZE.  219 

square  of  the  gauze  having  injected  between  its  folds  a  quan- 
tity of  the  liquid  about  equal  to  its  own  weight.  Then  it  is 
returned  to  the  stove  for  several  hours,  in  order  that  the 
mixture  may  be  equally  diffused ;  or  the  same  result  may  be 
obtained  by  the  action  of  a  press. 

Gauze  thus  prepared,  though  light,  is  flexible  and  firm,  is 
of  a  yellowish  color,  and  exhales  a  strong  odor  of  carbolic 
acid.  It  should  be  kept  in  an  air-tight  canister  to  protect  it 
from  heat,  which  favors  its  evaporation.  In  fact,  if  it  is 
warmed  even  by  the  heat  of  the  skin,  it  gradually  gives  up 
its  acid. 

This  prepared  gauze  is  the  most  expensive  part  of  the 
dressing,  because  so  much  of  it  is  used  ;  and  yet  it  was  well 
made  formerly  at  the  Edinburgh  Infirmary  for  less  than  six 
cents  a  meter ;  and  a  dressing  for  the  thigh  requires  scarcely 
two  meters.  In  Paris  one  can  hardly  get  it  for  ten  cents  a 
meter.  However,  all  the  large  pieces  may  be  washed  after 
they  have  been  used,  and  then  recharged  with  the  resinous 
mixture,  thus  effecting  a  considerable  saving  ;  for  the  great 
cost  is  in  the  gauze,  and  not  in  the  mixture  which  saturates 
it. 

Roller  bandages  made  of  this  material  are  remarkably 
good,  being  very  flexible  and  strong,  and  not  slipping  as 
ordinary  bandages  do. 

Various  other  materials  have  been  offered  as  substitutes 
for  the  gauze  ;  but  whatever  they  are,  certain  indispensable 
properties  should  be  required  of  them.  In  the  gauze,  the 
carbolic  acid  is  the  fermenticide.  The  resin  has  the  prop- 
erty of  holding  the  acid  a  long  time,  and  letting  it  escape  only 
very  slowly.  The  paraffin  is  a  neutral  substance,  but  it 
imparts  desirable  consistency,  does  not  change  the  resin,  and 
keeps  the  gauze  from  adhering  to  the  skin,  an  accident 
which  would  be  very  vexatious. 


220  ANTISEPTIC    SUBGERY. 


Protective. 

This  material  is  prepared  bj  coating  fine,  well-made  oil- 
silk  with  a  delicate  layer  of  copal  varnish,  and  applying 
outside  of  this  a  pellicle  of  dextrine.  It  is  not  in  itself  anti- 
septic, but  it  protects  the  wound  from  the  irritant  action  of 
the  carbolic  acid  in  the  gauze.  Simple  oil-silk  will  not  pre- 
vent the  passage  of  the  acid,  as  I  have  found  to  my  sorrow ; 
hence  the  application  of  the  varnish,  which  is  impermeable  to 
it.  The  dextrine  is  designed  to  retain  a  little  of  the  anti- 
septic solution  in  which  the  protective  is  dipped  before  being 
placed  on  the  wound. 

So  minute  a  quantity  of  the  protective  is  required  for  each 
wound  that  a  little  will  last  a  long  time,  and  its  cost  is  not 
worth  considering. 

In  preparing  it  we  take  common  oil-silk  and  cover  both 
surfaces  with  a  film  of  copal  varnish.  When  this  is  dry,  we 
apply  with  a  brush  a  thin  layer  of  the  following  mixture  :  — 

Dextrine 7  parts. 

Powdered  starch 2     " 

.  Cold  one-to-forty  solution  of  carbolic 

acid 16     " 

The  last  ingredient  is  used  to  facilitate  the  deposition  of  a 
pellicle  of  dextrine. 

Mackintosh. 

This  is  fine  and  flexible  cotton  cloth,  coated  with  a  deli- 
cate but  tough  layer  of  rubber.  The  flexibility  of  this  mate- 
rial is  remarkable,  for  it  will  stand  any  amount  of  crumpling 
without  cracking  or  breaking,  and  the  impermeable  layer 
does  not  peel  at  any  point.  This  is  an  important  quality 
from  an  economic  point  of  view,  for  it  permits  the  repeated  use 


THE  MACKINTOSH.  221 

of  the  mackintosh,  and  thus  saves  a  very  considerable  increase 
in  the  cost  of  the  dressing.  After  each  dressing  the  pieces 
of  this  material  should  be  put  into  soap-suds,  and  then 
allowed  to  remain  for  some  hours  in  the  strong  solution  of  car- 
bolic acid.  They  are  then  dried,  and,  at  the  next  dressing, 
just  before  putting  them  between  the  two  outer  layers  of  the 
gauze,  it  is  well  to  carefully  moisten  both  sides  with  the  weak 
solution,  in  order  to  destroy  the  germs  which  may  have  been 
deposited  upon  them.  In  this  way,  two  pieces  of  mackin- 
tosh can  be  made  to  answer,  as  well  as  more,  during  the  entire 
treatment  after  an  operation,  and,  indeed,  in  many  different 
cases,  thus  greatly  reducing  the  estimated  cost  of  the  dress- 
ings. The  least  solution  of  continuity  is  a  source  of  danger, 
and  every  piece  of  mackintosh  which  is  not  perfect  should  be 
thrown  away. 

In  Germany  they  use  thin  gutta-percha  instead  of  mackin- 
tosh, considering  it  less  expensive. 


Chloride  of  zinc. 

This  substance,  being  one  of  the  most  powerful  antiseptics 
known,  is  of  great  value.  The  persistence  of  its  antiseptic 
effect  is  the  peculiar  property  for  which  it  is  especially  cele- 
brated, and  therefore  it  is  called  for  in  cases  where  we  de- 
sire to  purify  infected  wounds  in  the  most  thorough  manner. 
The  solution  which  is  used  in  all  these  cases  is  the  fol- 
lowing :  — 

Chloride  of  zinc 8  grams, 

Water 100       " 

This  solution  is  very  caustic,  and  leaves  upon  the  wound- 
surfaces  which  it  touches  a  thin  eschar,  which,  however,  does 
not  hinder  union  by  first  intention.     Its  employment  is  iudi- 


222  ANTISEPTIC    SURGERY. 

cated  in  wounds  which  have  been  exposed  for  a  long  time, 
and  still  more  in  those  cases  where  complete  protection  by 
the  antiseptic  method  is  impossible.  I  would  recommend  it 
in  certain  cases  of  cold  abscess,  where  the  walls  of  the  cavity 
are  too  well  organized. 

But  I  would  especially  call  attention  to  its  employment 
where  carbolic  acid  cannot  be  used  for  fear  of  its  toxic 
effects.  We  must  then  content  ourselves  with  solutions  of 
one  or  two  per  cent.,  or  even  weaker.  My  experience  is  not 
sufficiently  varied  to  warrant  me  in  stating  the  exact  limit  of 
its  antiseptic  power. 

Catgut. 

The  manufacture  of  carbolized  catgut  is  so  poorly  under- 
stood by  makers  generally  that  I  would  advise  surgeons  to 
make  it  for  themselves,  and  refer  them  to  what  is  said  on 
this  point  in  the  chapter  on  ligatures. 

To  get  a  solid,  aseptic,  and  sufficiently  firm  thread,  the 
following  directions  should  be  exactly  observed  :  — 

Carbolic-acid  crystals 20  grams. 

Water 2      " 

Olive  oil 100      " 

Pour  the  water  upon  the  crystals,  and  then  make  an  emul- 
sion by  vigorously  shaking  the  dissolved  acid  with  the  oil. 
Put  this  into  a  bottle,  in  the  bottom  of  which  are  placed  some 
pebbles  or  glass  rods  to  keep  the  cord  from  touching  the 
water  which  settles  there.  Then  place  the  pieces  of  gut  in 
the  bottle,  seal  it  hermetically,  and  let  it  stand  five  or  six 
months.  The  cord  is  rarely  solid  before  the  end  of  this  term, 
and  the  longer  it  remains,  the  better  does  it  become  for  all 
purposes. . 

A  great  deal  depends  upon  the  original  quality  of  the  gut. 


BORACIC   ACID.  223 

That  which  we  find  in  commerce  is  usually  poor  stuff.  The 
very  fine  cords  are  useless,  except  for  some  particular  sutures. 
The  French  catgut  is  the  most  reliable,  and,  by  the  advice  of 
a  well-known  lute-maker,  I  select  the  unbleached  cords, 
which  endure  strain  the  best.  I  have  prepared  A^ery  large 
cords,  quite  sufficient  to  secure  the  pedicle  in  ovariotomy. 

Carholized  silk. 

In  cases  where  he  does  not  care  to  use  either  catgut  or  silver 
wire.  Lister  often  has  recourse  to  silk  thread.  This  is  pre- 
pared by  dipping  it  into  a  mixture  consisting  of  two  grams  of 
pure  carbolic  acid  and  sixteen  grams  of  melted  wax.  The 
thread  is  then  drawn  through  a  cloth,  in  order  to  distrib- 
ute the  wax  evenly  over  the  surface,  and  to  remove  the 
excess. 

Boracio  acid  and  its  preparations. 

Boracic  acid  is  an  excellent  antiseptic,  but  the  results  ob- 
tained with  it  as  a  topical  application  are  comparatively 
mediocre.  While  it  is  very  unfavorable  for  the  development 
of  the  phenomena  of  putrefaction,  it  does  not  powerfully 
modify  the  putrescible  substances  which  are  always  in  excess 
in  the  vicinity  of  wounds.  Its  moderate  solubility  makes  its 
use  as  a  wet  topical  unsatisfactory.  On  the  other  hand,  it 
has  the  advantage  of  being  neither  caustic  nor  irritant.  It 
renders  very  good  service  in  superficial  wounds  where  there 
is  no  prospect  of  a  considerable  discharge  ;  in  the  last  part  of 
the  treatment  of  a  wound ;  all  through  the  treatment,  when 
the  injured  parts  and  those  in  the  vicinity  are  peculiarly  liable 
to  irritation,  as  the  conjunctiva,  for  example ;  and  whenever 
large  injections  must  be  made  into  cavities  from  which  fluids 
return  imperfectly  or  with  difficulty. 


224  ANTISEPTIC    SUKGEKT. 

For  all  these  purposes  we  use  the  saturated  solution. 
Water  at  the  ordinary  temperature  will  hardly  hold  four  per 
cent,  of  its  weight  of  the  acid.  It  may,  however,  be  used  as 
a  dry  dressing  in  the  form  of 

Boracic  lint. 

Taking  advantage  of  the  power  of  boiling  water  to  dissolve 
nearly  a  third  of  its  weight  of  boracic  acid,  we  make  a  very 
valuable  preparation.  Into  boiling  water  which  is  saturated 
with  boracic  acid  we  dip  pieces  of  lint,  that  soft  and  porous 
cotton  material  which,  in  the  English  hospitals,  replaces 
charpie.  On  being  dried  they  are  found  to  have  almost 
doubled  in  weight.  In  fact,  their  interstices  and  surfaces 
are  covered  with  crystals  of  boracic  acid,  which  are  soft  and 
not  at  all  injurious  to  the  skin. 

In  using  boracic  lint,  we  moisten  it  in  a  solution  of  the 
acid,  apply  it  to  the  wound,  and  cover  it  in  with  the  mack- 
intosh. 

Boracic  ointment. 

This  is  a  somewhat  unappreciated  preparation,  but  it  is 
capable  of  rendering  capital  service  either  as  a  dressing  com- 
plete in  itself,  when  there  is  little  discharge,  or  in  case  we 
wish  to  introduce  an  unguent  into  a  carbolic  dressing.  Lis- 
ter gives  the  following  formula  :  — 

Pure  boracic  acid       ...  1  part  by  weight. 

White  wax 1    u      u         » 

Paraffin 2  parts  "         " 

Almond  oil 2    "      "         " 

Mix  the  wax  and  paraffin  by  heating  them  with  the  oil ;  then 
stir  them  up  thoroughly  with  powdered  boracic  acid  until 
the  mixture  thickens.     This  ointment  I  have  found   to  be 


PETROLEUM  JELLY.  225 

rather  hard  and  not  very  manageable,  and  I  prefer  that  which 
is  made  by  the  formula  below:  — 

Oil  of  sweet  almonds 210  grams, 

Paraffin 60      " 

White  wax 30      " 

Boracic  acid 60      " 

This  ointment  is  spread  on  fine,  soft  cotton  or  linen.  It  is 
an  excellent  application  to  wounds  in  the  vicinity  of  orifices, 
as  about  the  face,  favoring  union  by  first  intention,  being 
unirritating  and  a  good  antiseptic,  constantly  giving  up  the 
acid  to  the  liquids  which  drain  away.  It  is  very  serviceable 
even  in  cases  where  putrefaction  cannot  be  avoided,  and  one 
can  only  diminish  its  effects. 

Vaseline. 

This  transparent  and  unctuous  substance,  also  known  as 
petroleum  jelly,  is  a  product  derived  from  petroleum,  and, 
unlike  fats,  is  absolutely  imputrescible.  It  does  not  become 
rancid,  and  for  a  long  time  it  has  been  of  great  service  as  a 
substitute  for  the  greasy  topics,  especially  in  ophthalmic 
surgery.  Like  glycerine,  it  dissolves  many  medicinal  sub- 
stances. By  triturating  it  with  boracic  acid,  we  get  a  sort 
of  boracic  ointment  which  is  a  fine  antiseptic. 

In  his  recent  work,  ISTussbaum  advises  its  employment  to 
disinfect  the  hands  of  the  surgeon,  and  to  protect  them  from 
the  irritant  action  of  carbolic  acid.  He  says :  "  The  hands 
of  the  surgeon  who  has  much  operating  to  do  soon  become 
rough,  often  even  painful,  from  the  action  of  the  carbolic 
solution.  Therefore,  I  have  lately  anointed  my  hands  with 
carbolized  vaseline  made  by  the  following  recipe  :  — 

Carbolic-acid  crystals 10  grams, 

Vaseline 90      " 


226  ANTISEPTIC    SURGERY. 

This  mixture  penetrates  all  the  pores  and  creases,  thoroughly 
disinfects  the  hands,  and  prevents  their  becoming  rough." 


^Jute. 

Good  antiseptic  preparations  may  be  made  of  tow  impreg- 
nated with  antiseptic  substances.  There  are  cases  in  which 
oakum  gives  excellent  results.  On  account  of  its  cheapness, 
the  Germans  highly  recommend  a  material  which  is  called 
jute.  It  is  also  known  as  Arracan  hemp,  and  is  a  tow  made 
from  the  fibre  of  divers  varieties  of  corchorus,  especially  the 
corchorus  capsularis,  cultivated  in  Bengal,  and  for  a  long 
time  used  in  Europe  for  the  manufacture  of  coarse  mats  and 
bags. 

Thiersch,  who  has  particularly  advised  its  employment, 
salicylates  jute  by  soaking  it  in  the  following  solution,  and 
then  drying  it :  — 

Salicylic  acid 75  grams, 

Glycerine       500      " 

Water  at  80°  C 4,500      " 

We  may  also  impregnate  the  simple  jute  with  the  weak 
or  the  strong  solution  of  carbolic  acid,  just  as  we  would 
charpie. 

Drainage  tubes. 

Being  an  essential  part  of  the  dressing,  the  drainage  tubes 
should  always  be  prepared  in  advance.  We  select  firm  tubes, 
and  by  preference  take  the  red  or  black  rubber,  as  they 
are  much  purer  and  less  easily  acquire  odors  by  contact  with 
organic  matters.  They  are  prepared  by  fastening  a  single  or 
double  thread  to  one  end,  and  putting  them  into  a  wide- 
mouthed  bottle  filled  with  strong  carbolized  water,  in  which 


OTHER   GERMICIDES.  227 

they  are  kept  until  needed.  The  rubber  becomes  impreg- 
nated with  the  acid,  and  the  tubes  are  always  ready  for  use. 
.  Horsehair  is  prepared  for  drains  by  washing  it  in  an  alka- 
line solution  to  free  it  from  impurities  and  the  greasy  matters 
which  adhere  to  it,  then  doing  it  up  in  fasciculi  of  various 
sizes,  and  keeping  them  in  a  bottle  of  carbolized  water. 

Salicylic  and  thymic  acids. 

These  are  the  chief  rivals  of  carbolic  acid  ;  but,  in  spite  of 
their  real  value,  their  employment  has  always  been  extremely 
limited.  Thiersch,  of  Leipsic,  has  been  foremost  in  praise  of 
salicylic  acid,  but  his  results  have  been  greatly  inferior  to 
those  of  surgeons  who  use  the  carbolized  dressing. 

Salicylic  acid  is  so  irritant  to  the  respiratory  passages  that 
it  is  impossible  to  use  it  for  the  spray.  Even  the  handling 
of  pieces  of  dressing  which  are  well  impregnated  with  the 
acid  is  sufficient  to  annoy  the  assistants. 

Salicylic  acid  is  so  slightly  soluble  that  we  must  either 
employ  very  weak  aqueous  solutions  (one  part  to  three 
hundred),  or  add  a  considerable  quantity  of  alcohol. 

Thymic  acid  is  very  irritant  and  even  less  soluble  than 
the  salicylic.  The  solutions  which  are  employed  have  no 
antiseptic  value.  It  is,  moreover,  very  costly  —  an  objection 
of  no  moderate  consequence. 

The  antiseptic  gauze  made  with  thymol  or  thymic  acid,  in 
a  manner  similar  to  that  employed  in  making  carbolic  gauze, 
is  used  to  a  very  limited  extent.  It  is  worthy  of  note  that, 
at  the  last  congress  of  German  surgeons,  those  who  were  for- 
merly very  enthusiastic  admirers  of  thymic  acid  declared  that 
it  had  little  value,  and  that  they  had  been  obliged  to  return 
to  carbolic  acid.  This  was  a  result  which  could  easily  have 
been  predicted. 


228  ANTISEPTIC    SURGERY. 

For  "a  long  time  thymic  acid  had  been  used  in  France,  where 
it  was  known  as  an  antiseptic,  but  was  never  extensively  em- 
ployed on  account  of  its  irritant  and  caustic  qualities,  its 
insolubility,  and  its  costliness. 

Salicylic  wadding. 
It  is  proper  to  state  that  we  can  utilize  certain  prepara- 
tions like  salicylic  wadding  to  complete  a  dressing.  This  is 
wadding  impregnated  with  salicylic  acid,  by  immersing  it  in 
a  solution  of  the  acid  in  alcohol  and  water,  and  then  drying 
it.  The  quantity  of  acid  in  this  preparation  can  be  regulated 
by  making  a  stronger  or  weaker  solution.  Nussbaum's  method 
of  making  a  ten-per-cent.  salicylic  wadding  is  as  follows  :  — 

Salicylic  acid 1  kilogram. 

Alcohol 1        " 

Water  at  80°  C 60  liters. 

Dissolve  the  acid  in  the  alcohol,  and  add  the  water.  Take 
ten  kilograms  of  wadding  which  has  been  cleansed  of  grease, 
and  immerse  it  in  this  solution  for  several  hours.  Then 
spread  it  on  boards  to  dry. 

In  a  similar  way  salicylic  jute  is  prepared. 

Compound  preparations. 
An  idea  which  I  consider  fruitful  is  that  of  combining 
several  antiseptics.  I  have  had  but  little  experience  in  this 
line,  but  I  can  point  to  M.  Siredey,  who  associates  thymic 
with  carbolic  acids.  I  would  also  call  attention  to  the  pre- 
paration of  a  Paris  apothecary,  which  is  known  as  the  anti- 
septic liquor  of  Pennes,  and  contains  salicylic  and  thymic 
acids  and  the  essence  of  eucalyptus.  It  is  a  powerful  anti- 
septic. It  is  quite  probable  that  a  judicious  combination  of 
antiseptics  will  permit  us  to  reach  certain  kinds  of  micro- 
organisms, which  are  sensitive  to  a  compound  antiseptic 
only. 


A   USEFUL   ANTISEPTIC.  229 


Sulphite  of  sodium. 

It  may  be  worth  while  to  notice  the  employment  of  this 
substance,  so  highly  extolled  in  Italy.  According  to  the 
confession  of  Dr.  Angelo  Minich,  who  has  urged  its  method- 
ical employment  in  an  important  work  which  was  published 
in  Venice  in  1876,  it  is  inferior  to  carbolic  acid,  but  it  is 
plain  that,  in  some  cases,  we  may  make  use  of  a  good  part  of 
the  formulae  which  he  gives.  He  recommends  it  as  cheap, 
unirritant,  and  as  a  preventive  of  even  erysipelas.  For  the 
spray  and  dressings  he  uses  this  solution  :  — 

Sulphite  of  sodium 100  grams, 

Glycerine 50      " 

Water .  1,000      " 

He  makes  the  dressing  by  applying  a  layer  of  gutta-percha 
upon  the  wound,  strips  of  simple  gauze  steeped  in  the  solu- 
tion, a  thick  layer  of  purified  cotton,  and  a  bandage  of  gauze 
soaked  in  the  antiseptic  solution.  He  has  even  replaced  the 
wadding  with  flaxen  tow  or  salicylic  hemp.  The  dressing  is 
renewed  as  is  the  genuine  antiseptic  dressing. 

Cataplasms  are  replaced  by  compresses  saturated  with  the 
hot  solution. 

When  the  wound  begins  to  cicatrize,  the  wet  dressing  is 
no  longer  favorable,  and  Minich  advises  the  application  of  a 
cloth  spread  with  this  ointment :  — 

Tannate  of  lead 4  grams, 

Lard 30      « 

Sulphite  of  sodium 4      " 

Above  this  is  placed  a  layer  of  salicylic  wadding,  and  over 
all  a  thin  layer  of  gutta-percha. 


APPENDIX. 


Comparison  of  Some  of  the  Principal  Measures  of  the  Metric  System 
with  those  in  Coinmon  Use. 


MEASURES    OF    LEKGTH. 


1  Millimeter  =    0.03937  inch,  or  about  ^  inch. 
1  Centimeter  =    0.3937  inch,  or  about  -^Aj  inch. 
1  Meter  =  39.37  inches,  or  about  40  inches. 

1  Kilometer   =     0.62137  mile,  or  about  1100  yards. 

MEASURES    OF    WEIGHT. 

1  Milligram  =    0.0154  grain,  or  about  -^^  grain. 

1  Centigram  =    0.1543  grain,  or  about  ^  grain. 

1  Gram  =;  15.432  grains,  or  about  15 1-  grains. 

1  Kilogram  ^=.    2.2046  avoirdupois  pounds,  or  about  2^  pounds. 

MEASURES     OF    CAPACITY. 

1  Milliliter  or  cubic  centimeter  :=. 

16.2293  minims,  or  about  16  minims. 
1  Liter  =    2.1132  pints   (U.  S.  wine  measure),  or  about  2  pints,  1 
fluid  ounce. 


232 


APPENDIX. 


Comparison  of  Thermometric  Scales. 


Centigrade. 

Fahrenheit. 

Centigrade. 

Fahrenheit 

0. 

32. 

40.5 

105. 

10. 

50. 

41. 

105.8 

20. 

68. 

41.1 

106. 

25. 

77. 

41.2 

106.2 

30. 

86. 

41.6 

107. 

35. 

95. 

42. 

107.6 

35.5 

96. 

42.2 

108. 

36.1 

97. 

42.5 

108.5 

36.6 

98. 

42.7 

109. 

37. 

98.6 

43. 

109.4 

37.2 

99. 

43.3 

110. 

37.5 

99.5 

43.9 

111. 

37.7 

100. 

44.4 

112. 

38. 

100.4 

50. 

122. 

38.3 

101. 

60. 

140. 

38.7 

101.7 

70. 

158. 

38.9 

102. 

80. 

176. 

39. 

102.2 

90. 

194. 

39.4 

103. 

100. 

212. 

40. 

104. 

INDEX. 


Abscesses,  acute 180 

cold 182 

congestive 182 

Accouchement 169 

Alcohol,  an  antiseptic 21 

Amputations 128 

Anaesthetic  action  of  carbolic  acid 207 

Antiseptic  method,  objections  to 204 

Antiseptics  anciently  used 19 

compound 228 

Bone  drainage-tubes 71 

Boracic  acid 58,  223 

Boracic  lint 224 

Boracic  ointment 224 

Caesarean  section 158 

Callus,  resection  of  vicious 124 

Carbolic  acid 214 

an  angesthetic 207 

eczema  produced  by 203 

irritant  action  of 208 

poisoning  by 200 

solutions  of     .     .     .     -. 216 

Carbolized  glycerine .217 

Carbolized  oil   ... 217 

Carbolized  silk 223 

Castration 187 

16 


234  INDEX. 

Catgut  ~ 83 

as  a  ligature 85,  177 

as  a  suture 87 

for  drainage 70 

preparation  of 84,  222 

Championniere's  spray-producer 77 

Clots,  assisting  repair 94 

Club-foot 189 

Codman  &  ShurtlefF's  spray-producer 81 

Comparison  of  metric  and  common  measures 230 

of  thermoraetric  scales 230 

Compression  witli  sponge 45 

Cost  of  the  dressing 207 

Defence  against  germs  after  operation 38 

Destruction  of  germs  before  operation 34 

during  operation 36 

Disarticulations 130 

Dislocations,  operations  to  relieve      .     .     . 136 

Drainage,  conditions  of 67 

how  affected 40 

tubes 226 

absorbable 171 

method  of  using 68 

rubber 67 

with  catgut 70 

with  horse-hair 71 

Dressing,  the 43 

cost  of 207 

of  old  wounds 53 

of  wounds  near  natural  orifices 53 

indications  for  renewal  of 47 

time  for  omission  of     .     .     .' 60 

Eczema,  carbolic 203 

Empyema 185 

Excision  of  joints 143 

Eye,  operations  on  the 194 


INDEX. 


285 


False  joints,  resection  of 126 

Female  genitals,  surgery  of 164 

Fibrous  tumors  of  uterus 1 68 

Fistula,  vesico-yaginal 167 

Foreign  bodies,  removal  of,  from  joints 134 

Formulae  for  preparing  antiseptic  materials 214 

Fractures,  compound 119 

ununited 136 

Gastrotomy 163 

Gauze,  preparation  of 218 

Genitals,  surgery  of  female 164 

Genu  valgum 125 

Germs,  a  cause  of  suppuration 28 

defence  against 38 

destruction  of 34,  36 

the  cause  of  putrefaction 25 

Gilbrin's  experience 114 

Glycerine,  carbolized 217 

Grafting 191 

Guerin's  wadded  dressing 19 

Gunshot  wounds 123 

Hanks's  spray-producer 82 

Healthfulness  of  antiseptic  hospitals 197 

Hernia,  radical  cure  of 149 

strangulated 146 

Horse-hair  for  a  drain 71 

Hospitals,  influence  of  Listerism  on 197 

Hydatids  of  liver 163 

Hydrarthrosis 136 

Hydrocele 188 

Inflammation,  absence  of 95 

Irritation,  a  cause  of  suppuration 27 

prevention  of 42 

Joints,  irrigation  of  inflamed 141 

opening  of  diseased 137 


236  ~  INDEX. 

Joints,  resection  of 143 

wounds  of 132 

Jute 226 

Kelotomy 146 

Laparotomy,  for  internal  strangulation 152 

Larrey's  dressings 18 

Lead  plates  to  confine  deep  sutures 42 

Ligation  of  vessels 176 

Lint,  boracic 224 

Listerism,  its  influence  on  hospitalism 197 

the  theory  of  .     .     .         25 

Lister's  experience  in  Glasgow 105 

spray-producer 76 

Lithotomy,  hypogastric 185 

Liver,  hydatid  cysts  of 163 

Mackintosh,  preparation  of 220 

Metric  measures  compared  with  common 231 

Micro-organisms,  absence  of 102 

Natural  orifices,  wounds  near 56 

Nephrotomy 163 

Nerves,  excision  of 129 

Objections  to  antiseptic  method 204 

Obstetric  practice 169 

Occlusion  dressings 18 

Oil,  carbolized 217 

Ointment,  boracic 224 

Old  wounds,  dressing  of 53 

Omission  of  dressing,  time  for 60 

Oophorectomy 163 

Operations  on  peritoneum 146 

Ophthalmic  surgery 194 

Osteotomy 124 

Ovariotomy 154 


INDEX.  237 

Pain,  freedom  from 95 

Pasteur's  discoveries 23 

Perineorrhaphy 167 

Peritoneum,  operations  on 146 

Plaster  bandage  in  compound  fractures 121 

Plastic  operations 115 

Poisoning  by  carbolic  acid 200 

Porro's  operation 158 

Practice  of  the  dressing ' 33 

Preparation  of  antiseptic  materials 214 

Protection  of  surgeon 198 

Protective,  preparation  of  the 220 

Putrefaction,  caused  by  germs 25 

Rachitic  curvatures 125 

Renewal  of  dressing,  indications  for 47 

Repair,  influence  of  Listerism  on 89 

phenomena  of 90 

rapidity  of 91 

regularity  of 95 

Resection  of  joints 143 

Results  of  the  dressing 104 

Richardson's  spray-producer 75 

Rubber  drainage-tubes 67 

Ruptured  perineum 167 

Salicylic  acid 227 

Salicylic  wadding 228 

Saxtorph's  experience 107 

Silk,  carbolized 223 

Sodium,  sulphite  of 229 

Solutions  of  carbolic  acid 216 

Sponge,  compression  with     . 45 

Spray,  the  antiseptic 73 

management  of        37 

Spray-producer,  Championniere's 77 

Codman  &  ShurtlefE's       81 

Hanks's 82 


238  INDEX, 

Spray-producer,  Lister's 76 

principles  of 75 

Richardson's 75 

Weir's 82 

Strangulation,  laparotomy  for  internal 152 

Substitutes  for  Lister's  method ■.     .     .     .  212 

Suppuration,  an  obstacle  to  repair 26 

caused  by  germs 28 

conditions  favorable  to 27 

Sutures,  deep 63 

materials  for 65 

superficial 62 

Talipes 189 

Tendons,  operations  on 189 

Tension,  excessive,  a  cause  of  suppuration 27 

prevention  of  excessive 40 

Theory  of  Listerism 25 

Thermometric  scales,  comparison  of 232 

Thymic  acid .^ 227 

Traumatic  fever,  cause  of 92 

Trephining 190 

Tumors  of  uterus,  fibrous 168 

Tumors,  removal  of 116 

Ulcers 191 

Union  by  first  intention 115 

Ununited  fractures 136 

Uterus,  fibrous  tumors  of 168 

Vagina,  obliteration  of 164 

Varix,  radical  cure  of 178 

Vaseline 225 

Vesico-vaginal  fistula 167 

Vessels,  ligation  of 176 

Volkmann's  experience 109 

Wadded  dressing  of  Guerin 19 

Wadding,  salicylic 228 


INDEX.  239 

Weir's  spray  producer 82 

White  swellings,  opening  of 141 

Wound  complications,  absence  of 101 

Wounds  near  natural  orifices 53 

Wounds,  dressing  of  recent 53 

dressing  of  suppurating 54 

which  cannot  be  closed 59 

Zinc,  chloride  of ' 221 


THE    END. 


Other  Works  by  Dr.  Championniere. 

In  French. 

The   Uterine   Lymphatics    and  Uterine  Lymphangitis.      The  part  played  by 
lymphangitis  in  puerperal  complications  and  uterine  diseases.     1870. 

The  Lymphatics  of  the  Womb  and  their  ?o/e  in  uterine  pathology.     1875. 

Traumatic  Fever.     1872. 

Historical  and  Clinical  Study  of  Trephining  of  the  Skull. 

Journal  of  Practical  Medicine  and  Surgery.    A  monthly  magazine  of  forty-eight 
pages. 

Practitioners'  Dictionary.     A  complete  and  alphabetical  index  to  the  first  forty 
annual  volumes  of  the  Journal  of  Practical  Medicine  and  Surgery. 


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